Glucocorticoid receptor modulators to treat cervical cancer

ABSTRACT

Methods for treating a subject having a cancerous tumor are disclosed. The methods comprise administering to the subject an effective amount of a non-steroidal selective glucocorticoid receptor modulator (SGRM) and an effective amount of a chemotherapeutic agent. The tumor may be cervical cancer. The SGRM may be a fused azadecalin. In embodiments, the SGRM may be a heteroaryl ketone fused azadecalin or an octahydro fused azadecalin.

CROSS-REFERENCE TO RELATED APPLICATION

This application claims priority to, and the benefit of, U.S.Provisional Patent application Ser. No. 62/480,226, filed Mar. 31, 2017,the entire contents of which is hereby incorporated by reference in itsentirety.

BACKGROUND

Cancer is a leading cause of death in the United States. For example,cervical cancer often has a poor prognosis, even when diagnosed early,and signs and symptoms may not appear until the cancer is quite advancedand complete surgical removal is not possible.

Conventional treatment options for cancers such as cervical cancerinclude surgery, radiation therapy and chemotherapy. Not all cancers,and not all cervical cancers, are resectable at the time of diagnosis.Tumors such as cervical cancer tumors that are at an advanced stageoften require radiotherapy or chemotherapy treatment.

Radiotherapy requires maximized exposure of the affected tissues whilesparing normal surrounding tissues. Interstitial therapy, where needlescontaining a radioactive source are embedded in the tumor, has become avaluable new approach. In this way, large doses of radiation can bedelivered locally while sparing the surrounding normal structures.Intraoperative radiotherapy, where the beam is placed directly onto thetumor during surgery while normal structures are moved safely away fromthe beam, is another specialized radiation technique. Again, thisachieves effective irradiation of the tumor while limiting exposure tosurrounding structures. Despite the obvious advantage of approachespredicated upon local control of the irradiation, patient survival rateis still very low.

Chemotherapy relies upon a generalized damage to DNA and destabilizationof chromosomal structure which eventually leads to destruction of cancercells. The non-selective nature of these treatments, however, oftenresults in severe and debilitating side effects. The systemic use ofthese drugs may result in damage to normally healthy organs and tissues,and compromise the long-term health of the patient.

The effects of glucocorticoid receptor (“GR”) mediated signaling pathwayon cancer cells in general are controversial. On one hand, it isbelieved that activating the GR signaling pathways advantageouslyinduces apoptosis in malignant lymphoid cancers. See Schlossmacher, J.Endocrino. (2011) 211, 17-25. On the other hand, it has been reportedthat agents blocking the GR signaling pathway can potentiatechemotherapy in killing breast cancer cells. See U.S. Pat. No.9,149,485. Mifepristone, a steroidal, non-selective agent that blocksthe GR signaling pathway and other steroidal signaling pathways(including progesterone-receptor signaling pathway), has been suggestedfor treatment of cervical cancer (US Pat. Publ. No. 2004/0102422).However, GR signaling is believed to have the opposite effect in someother cancers. For example, the prevailing view regarding pancreaticcancer is that glucocorticoid, e.g., dexamethasone, can relieve sideeffects of the chemotherapeutic agent and should be co-administered withchemotherapeutic agents in treating pancreatic cancer. Zhang et al., BMCCancer, 2006 Mar. 15 6: 61. Further, it has been reported thatdexamethasone, a glucocorticoid receptor agonist, inhibits pancreaticcancer cell growth. See, Normal et al., J. Surg. Res. 1994 July; 57(1):33-8. Thus, the reposts in the literature are often contradictory, andit remains unclear whether or not glucocorticoid signaling will have aneffect on a cancer, and whether such an effect may be a positive or anegative effect.

Accordingly, in view of the lack of good treatments options for manycancer patients, improved treatments for cancerous tumors, includingcervical cancer, are desired.

SUMMARY

Disclosed herein are novel methods for treating a subject hosting acancerous tumor, such as a cervical cancer tumor or other canceroustumor (e.g., breast cancer, ovarian cancer, prostate cancer). Thepresent application provides novel and surprising combination therapiesthat employ non-steroidal compounds that inhibit GR signaling to treatpatients suffering from cancer, including patients suffering fromcervical cancer and other cancers. The methods comprise administering tothe subject an effective amount of a chemotherapeutic agent and aneffective amount of a non-steroidal selective glucocorticoid receptormodulator (SGRM) to reduce the tumor load of the cancerous tumor in thesubject. In some cases, the cancerous tumor is a cervical cancer tumor.

In some cases, the chemotherapeutic agent is selected from the groupconsisting of antimicrotubule agents, alkylating agents, topoisomeraseinhibitors, endoplasmic reticulum stress inducing agents,antimetabolites, mitotic inhibitors and combinations thereof. In somecases, the chemotherapeutic agent is a taxane. In some cases, thechemotherapeutic agent is selected from the group consisting ofnab-paclitaxel, 5-fluorouracil (5-FU), gemcitabine, cisplatin andcapecitabine.

In some cases, the glucocorticoid receptor modulator is orallyadministered. In some cases, the glucocorticoid receptor modulator isadministered by transdermal application, by a nebulized suspension, orby an aerosol spray.

In some cases, the effective amount of the SGRM is a daily dose ofbetween 1 and 100 mg/kg/day, wherein the SGRM is administered with atleast one chemotherapeutic agent. In some embodiments, the daily dose ofthe SGRM is 1, 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 30, 40, 50 60, 70,80, 90 or 100 mg/kg/day. In some cases, the glucocorticoid receptormodulator is administrated for at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 25, 30, 35, 40, 45, 50, 55, 60,65, 70, 75, or 80 weeks.

In some cases, the glucocorticoid receptor modulator backbone is a fusedazadecalin. In some cases, the fused azadecalin is a compound having thefollowing formula:

wherein L¹ and L² are members independently selected from a bond andunsubstituted alkylene; R¹ is a member selected from unsubstitutedalkyl, unsubstituted heteroalkyl, unsubstituted heterocycloalkyl,—OR^(1A), NR^(1C)R^(1D), —C(O)NR^(1C)R^(1D), and —C(O)OR^(1A), whereinR^(1A) is a member selected from hydrogen, unsubstituted alkyl andunsubstituted heteroalkyl, R^(1C) and R^(1D) are members independentlyselected from unsubstituted alkyl and unsubstituted heteroalkyl, whereinR^(1C) and R^(1D) are optionally joined to form an unsubstituted ringwith the nitrogen to which they are attached, wherein said ringoptionally comprises an additional ring nitrogen; R² has the formula:

wherein R^(2G) is a member selected from hydrogen, halogen,unsubstituted alkyl, unsubstituted heteroalkyl, unsubstitutedcycloalkyl, unsubstituted heterocycloalkyl, —CN, and —CF₃; J is phenyl;t is an integer from 0 to 5; X is —S(O₂)—; and R⁵ is phenyl optionallysubstituted with 1-5 R^(5A) groups, wherein R^(5A) is a member selectedfrom hydrogen, halogen, —OR^(5A1), S(O₂)NR^(5A2)R^(5A3), —CN, andunsubstituted alkyl, wherein R^(5A1) is a member selected from hydrogenand unsubstituted alkyl, and R^(5A2) and R^(5A3) are membersindependently selected from hydrogen and unsubstituted alkyl, or saltsand isomers thereof.

In some cases, the fused azadecalin is

In some cases, the glucocorticoid receptor modulator backbone is aheteroaryl ketone fused azadecalin or an octahydro fused azadecalin. Insome cases, the heteroaryl ketone fused azadecalin has the formula:

wherein R¹ is a heteroaryl ring having from 5 to 6 ring members and from1 to 4 heteroatoms each independently selected from the group consistingof N, O and S, optionally substituted with 1-4 groups each independentlyselected from R^(1a); each R^(1a) is independently selected from thegroup consisting of hydrogen, C₁₋₆ alkyl, halogen, C₁₋₆ haloalkyl, C₁₋₆alkoxy, C₁₋₆ haloalkoxy, CN, N-oxide, C₃₋₈ cycloalkyl, and C₃₋₈heterocycloalkyl; ring J is selected from the group consisting of acycloalkyl ring, a heterocycloalkyl ring, an aryl ring and a heteroarylring, wherein the heterocycloalkyl and heteroaryl rings have from 5 to 6ring members and from 1 to 4 heteroatoms each independently selectedfrom the group consisting of N, O and S; each R² is independentlyselected from the group consisting of hydrogen, C₁₋₆ alkyl, halogen,C₁₋₆ haloalkyl, C₁₋₆ alkoxy, C₁₋₆ haloalkoxy, C₁₋₆ alkyl-C₁₋₆ alkoxy,CN, OH, NR^(2a)R^(2b), C(O)R^(2a), C(O)OR^(2a), C(O)NR^(2a)R^(2b),SR^(2a), S(O)R^(2a), S(O)₂R^(2a), C₃₋₈ cycloalkyl, and C₃₋₈heterocycloalkyl, wherein the heterocycloalkyl groups are optionallysubstituted with 1-4 R^(2c) groups; alternatively, two R² groups linkedto the same carbon are combined to form an oxo group (═O);alternatively, two R² groups are combined to form a heterocycloalkylring having from 5 to 6 ring members and from 1 to 3 heteroatoms eachindependently selected from the group consisting of N, O and S, whereinthe heterocycloalkyl ring is optionally substituted with from 1 to 3R^(2d) groups; R^(2a) and R^(2b) are each independently selected fromthe group consisting of hydrogen and C₁₋₆ alkyl; each R^(2c) isindependently selected from the group consisting of hydrogen, halogen,hydroxy, C₁₋₆ alkoxy, C₁₋₆ haloalkoxy, CN, and NR^(2a)R^(2b;) eachR^(2d) is independently selected from the group consisting of hydrogenand C₁₋₆ alkyl, or two R^(2d) groups attached to the same ring atom arecombined to form (═O); R³ is selected from the group consisting ofphenyl and pyridyl, each optionally substituted with 1-4 R^(3a) groups;each R^(3a) is independently selected from the group consisting ofhydrogen, halogen, and C₁₋₆ haloalkyl; and subscript n is an integerfrom 0 to 3; or salts and isomers thereof.

In some cases, the heteroaryl-ketone fused azadecalin is

In some cases, the octahydro fused azadecalin has the formula:

wherein R¹ is a heteroaryl ring having from 5 to 6 ring members and from1 to 4 heteroatoms each independently selected from the group consistingof N, O and S, optionally substituted with 1-4 groups each independentlyselected from R^(1a), each R^(1a) is independently selected from thegroup consisting of hydrogen, C₁₋₆ alkyl, halogen, C₁₋₆ haloalkyl, C₁₋₆alkoxy, C₁₋₆ haloalkoxy, N-oxide, and C₃₋₈ cycloalkyl; ring J isselected from the group consisting of an aryl ring and a heteroaryl ringhaving from 5 to 6 ring members and from 1 to 4 heteroatoms eachindependently selected from the group consisting of N, O and S; each R²is independently selected from the group consisting of hydrogen, C₁₋₆alkyl, halogen, C₁₋₆ haloalkyl, C₁₋₆ alkoxy, C₁₋₆ haloalkoxy, C₁₋₆alkyl-C₁₋₆ alkoxy, CN, OH, NR^(2a)R^(2b), C(O)R^(2a), C(O)OR^(2a),C(O)NR^(2a)R^(2b), SR^(2a), S(O)R^(2a), S(O)₂R^(2a), C₃₋₈ cycloalkyl,and C₃₋₈ heterocycloalkyl having from 1 to 3 heteroatoms eachindependently selected from the group consisting of N, O and S;alternatively, two R² groups on adjacent ring atoms are combined to forma heterocycloalkyl ring having from 5 to 6 ring members and from 1 to 3heteroatoms each independently selected from the group consisting of N,O and S, wherein the heterocycloalkyl ring is optionally substitutedwith from 1 to 3 R^(2c) groups; R^(2a), R^(2b) and R^(2c) are eachindependently selected from the group consisting of hydrogen and C₁₋₆alkyl; each R^(3a) is independently halogen; and subscript n is aninteger from 0 to 3, or salts and isomers thereof.

In some cases, the SGRM is CORT125134, i.e.,(R)-(1-(4-fluorophenyl)-6-((1-methyl-1H-pyrazol-4-yl)sulfonyl)-4,4a,5,6,7,8-hexahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone,which has the following structure:

In some cases, the SGRM is CORT125281, i.e.,((4aR,8aS)-1-(4-fluorophenyl)-6-((2-methyl-2H-1,2,3-triazol-4-yl)sulfonyl)-4,4a, 5,6,7,8,8a,9-octahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone,which has the following structure:

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows tumor growth data from five groups of mice that weretreated with 1) intravenous (i.v.) vehicle; 2) i.v. paclitaxel at 7.5mg/kg; 3) CORT125134 (30 mg/kg) and paclitaxel (7.5 mg/kg); 4) i.v.paclitaxel at 15 mg/kg; and 5) CORT125134 (30 mg/kg) and paclitaxel (15mg/kg).

FIG. 2 shows the effect of CORT125134 in combination with paclitaxel ina triple negative breast cancer (TNBC) mouse xenograft model. 10 miceper group, CORT125134 administered orally every day, intravenouspaclitaxel administered every 4 days. Data represent mean+SEM.

FIG. 3 shows the effect of CORT125134 in combination withgemcitabine/carboplatin in an ovarian cancer mouse xenograft model. 10mice per group, CORT125134 was administered intraperitoneally (i.p.) ondays 43, 44, 50 and 51, and gemcitabine/carboplatin was administeredi.p. on days 44 and 51. Data represent mean values.

FIG. 4 shows the effect of CORT125134 in combination with castration ina prostate cancer (CRPC) mouse xenograft model. 10 mice per group,CORT125134 was administered orally daily for 21 days. Data representmean+SEM.

DETAILED DESCRIPTION A. Introduction

This method disclosed herein can be used to treat a patient hosting acancerous tumor by administering an effective amount of a SGRM incombination with an effective amount of chemotherapy to reduce thecancerous tumor load. In embodiments, the cancer is cervical cancer.Applicant has discovered that treatments combining a SGRM with achemotherapeutic agent is more effective than treatments with thetherapeutic alone.

B. Definitions

As used herein, the term “tumor” and the term “cancer” are usedinterchangeably and both refer to an abnormal growth of tissue thatresults from excessive cell division. A tumor that invades thesurrounding tissue and/or can metastasize is referred to as “malignant.”A tumor that does not metastasize is referred to as “benign.”

As used herein, the term “subject” or “patient” refers to a human ornon-human organism. Thus, the methods and compositions described hereinare applicable to both human and veterinary disease. In certainembodiments, subjects are “patients,” i.e., living humans that arereceiving medical care for a disease or condition. This includes personswith no defined illness who are being investigated for signs ofpathology. Preferred are subjects who have an existing diagnosis of acervical cancer which is being targeted by the compositions and methodsof the present invention. In some cases, a subject may suffer from oneor more types of cancer simultaneously, at least one of which is acervical cancer, which is targeted by the compositions and methods ofthe present invention.

As used herein, the term “cancerous tumor” refers to any solid orsemi-solid malignant neoplastic growth.

As used herein, the term “cervical cancer” refers to any tumor in thecervix of a patient, or derived from the cervix of a patient.

As used herein, the term “tumor load” or “tumor burden” generally refersto the number of cancer cells, the size of a tumor, or the amount ofcancer in the body in a subject at any given time. Tumor load can bedetected by e.g., measuring the expression of tumor specific geneticmarkers and measuring tumor size by a number of well-known, biochemicalor imaging methods disclosed herein, infra.

As used herein, the term “effective amount” or “therapeutic amount”refers to an amount of a pharmacological agent effective to treat,eliminate, or mitigate at least one symptom of the disease beingtreated. In some cases, “therapeutically effective amount” or “effectiveamount” can refer to an amount of a functional agent or of apharmaceutical composition useful for exhibiting a detectabletherapeutic or inhibitory effect. The effect can be detected by anyassay method known in the art. The effective amount can be an amounteffective to invoke an antitumor response. For the purpose of thisdisclosure, the effective amount of SGRM or the effective amount of achemotherapeutic agent is an amount that would reduce tumor load orbring about other desired beneficial clinical outcomes related to cancerimprovement when combined with a chemotherapeutic agent or SGRM,respectively.

As used herein, the terms “administer,” “administering,” “administered”or “administration” refer to providing a compound or a composition(e.g., one described herein), to a subject or patient.

As used herein, the term “combination therapy” refers to theadministration of at least two pharmaceutical agents to a subject totreat a disease. The two agents may be administered simultaneously, orsequentially in any order during the entire or portions of the treatmentperiod. The at least two agents may be administered following the sameor different dosing regimens. In some cases, one agent is administeredfollowing a scheduled regimen while the other agent is administeredintermittently. In some cases, both agents are administeredintermittently. In some embodiments, the one pharmaceutical agent, e.g.,a SGRM, is administered daily, and the other pharmaceutical agent, e.g.,a chemotherapeutic agent, is administered every two, three, or fourdays.

As used herein, the term “compound” is used to denote a molecular moietyof unique, identifiable chemical structure. A molecular moiety(“compound”) may exist in a free species form, in which it is notassociated with other molecules. A compound may also exist as part of alarger aggregate, in which it is associated with other molecule(s), butnevertheless retains its chemical identity. A solvate, in which themolecular moiety of defined chemical structure (“compound”) isassociated with a molecule(s) of a solvent, is an example of such anassociated form. A hydrate is a solvate in which the associated solventis water. The recitation of a “compound” refers to the molecular moietyitself (of the recited structure), regardless of whether it exists in afree form or an associated form.

As used herein, the term “pharmaceutically acceptable carrier” isintended to include any and all solvents, dispersion media, coatings,antibacterial and antifungal agents, isotonic and absorption delayingagents, and the like, compatible with pharmaceutical administration. Theuse of such media and agents for pharmaceutically active substances iswell known in the art. Except insofar as any conventional media or agentis incompatible with the active compound, use thereof in thecompositions is contemplated. Supplementary active compounds can also beincorporated into the compositions.

The term “glucocorticosteroid” (“GC”) or “glucocorticoid” refers to asteroid hormone that binds to a glucocorticoid receptor.Glucocorticosteroids are typically characterized by having 21 carbonatoms, an α,β-unsaturated ketone in ring A, and an a-ketol groupattached to ring D. They differ in the extent of oxygenation orhydroxylation at C-11, C-17, and C-19; see Rawn, “Biosynthesis andTransport of Membrane Lipids and Formation of Cholesterol Derivatives,”in Biochemistry, Daisy et al. (eds.), 1989, pg. 567.

As used herein, the term “Glucocorticoid receptor” (“GR”) refers to afamily of intracellular receptors which specifically bind to cortisoland/or cortisol analogs. The glucocorticoid receptor is also referred toas the cortisol receptor. The term includes isoforms of GR, recombinantGR and mutated GR. “Glucocorticoid receptor” (“GR”) refers to the typeII GR which specifically binds to cortisol and/or cortisol analogs suchas dexamethasone (See, e.g., Turner & Muller, J. Mol. Endocrinol. Oct.1, 2005 35 283-292).

“Glucocorticoid receptor modulator” refers to any compound whichinhibits any biological response associated with the binding of GR to anagonist. For example, a GR agonist, such as dexamethasone, increases theactivity of tyrosine aminotransferase (TAT) in HepG2 cells (a humanliver hepatocellular carcinoma cell line; ECACC, UK). Accordingly, GRmodulators of the present invention can be identified by measuring theability of the compound to inhibit the effect of dexamethasone. TATactivity can be measured as outlined in the literature by A. Ali et al.,J. Med. Chem., 2004, 47, 2441-2452. A modulator is a compound with anIC₅₀ (half maximal inhibition concentration) of less than 10 micromolar.See Example 1, infra.

As used herein, the term “selective glucocorticoid receptor modulator”refers to any composition or compound which inhibits any biologicalresponse associated with the binding of a GR to an agonist. By“selective,” the drug preferentially binds to the GR rather than othernuclear receptors, such as the progesterone receptor (PR), themineralocorticoid receptor (MR) or the androgen receptor (AR). It ispreferred that the selective glucocorticoid receptor modulator bind GRwith an affinity that is 10×greater (1/10^(th) the K_(d) value) than itsaffinity to the MR, AR, or PR, both the MR and PR, both the MR and AR,both the AR and PR, or to the MR, AR, and PR. In a more preferredembodiment, the selective glucocorticoid receptor modulator binds GRwith an affinity that is 100×greater (1/100^(th) the K_(d) value) thanits affinity to the MR, AR, or PR, both the MR and PR, both the MR andAR, both the AR and PR, or to the MR, AR, and PR. In another embodiment,the selective glucocorticoid receptor modulator binds GR with anaffinity that is 1000×greater (1/1000^(th) the K_(d) value) than itsaffinity to the MR, AR, or PR, both the MR and PR, both the MR and AR,both the AR and PR, or to the MR, AR, and PR.

As used herein, the term “composition” is intended to encompass aproduct comprising the specified ingredients such as the said compounds,their tautomeric forms, their derivatives, their analogues, theirstereoisomers, their polymorphs, their deuterated species, theirpharmaceutically acceptable salts, esters, ethers, metabolites, mixturesof isomers, their pharmaceutically acceptable solvates andpharmaceutically acceptable compositions in specified amounts, as wellas any product which results, directly or indirectly, from combinationof the specified ingredients in the specified amounts. Such term inrelation to a pharmaceutical composition is intended to encompass aproduct comprising the active ingredient (s), and the inert ingredient(s) that make up the carrier, as well as any product which results,directly or indirectly, in combination, complexation or aggregation ofany two or more of the ingredients, or from dissociation of one or moreof the ingredients, or from other types of reactions or interactions ofone or more of the ingredients. Accordingly, the pharmaceuticalcompositions of the present invention are meant to encompass anycomposition made by admixing compounds of the present invention andtheir pharmaceutically acceptable carriers.

In some embodiments, the term “consisting essentially of” refers to acomposition in a formulation whose only active ingredient is theindicated active ingredient, however, other compounds may be includedwhich are for stabilizing, preserving, etc. the formulation, but are notinvolved directly in the therapeutic effect of the indicated activeingredient. In some embodiments, the term “consisting essentially of”can refer to compositions which contain the active ingredient andcomponents which facilitate the release of the active ingredient. Forexample, the composition can contain one or more components that provideextended release of the active ingredient over time to the subject. Insome embodiments, the term “consisting” refers to a composition, whichcontains the active ingredient and a pharmaceutically acceptable carrieror excipient.

As used herein, the phrase “non-steroidal backbone” in the context ofSGRMs refers to SGRMs that do not share structural homology to, or arenot modifications of, cortisol with its steroid backbone containingseventeen carbon atoms, bonded in four fused rings. Such compoundsinclude synthetic mimetics and analogs of proteins, including partiallypeptidic, pseudopeptidic and non-peptidic molecular entities.

Non-steroidal SGRM compounds include SGRMs having a fused azadecalinbackbone, a heteroaryl ketone fused azadecalin backbone, and anoctahydro fused azadecalin backbone. Exemplary glucocorticoid receptormodulators having a fused azadecalin backbone include those described inU.S. Pat. Nos. 7,928,237 and 8,461,172. Exemplary glucocorticoidreceptor modulators having a heteroaryl ketone fused azadecalin backboneinclude those described in U.S. Pat. No. 8,859,774, entitledHeteroaryl-Ketone Fused Azadecalin Glucocorticoid Receptor Modulators.Exemplary glucocorticoid receptor modulators having an octohydro fusedazadecalin backbone include those described in U.S. Patent ApplicationPublication No. 2015-0148341 A1, entitled Octahydro Fused AzadecalinGlucocorticoid Receptor Modulators, filed on Nov. 21, 2014.

Where substituent groups are specified by their conventional chemicalformulae, written from left to right, they equally encompass thechemically identical substituents that would result from writing thestructure from right to left, e.g., —CH₂O— is equivalent to —OCH₂—.

“Alkyl” refers to a straight or branched, saturated, aliphatic radicalhaving the number of carbon atoms indicated. Alkyl can include anynumber of carbons, such as C₁₋₂, C₁₋₃, C₁₋₄, C₁₋₅, C₁₋₆, C₁₋₇, C₁₋₈,C₁₋₉, C₁₋₁₀, C₂₋₃, C₂₋₄, C₂₋₅, C₂₋₆, C₃₋₄, C₃₋₅, C₃₋₆, C₄₋₅, C₄₋₆, andC₅₋₆. For example, C₁₋₆ alkyl includes, but is not limited to, methyl,ethyl, propyl, isopropyl, butyl, isobutyl, sec_butyl, tert_butyl,pentyl, isopentyl, and hexyl.

“Alkoxy” refers to an alkyl group having an oxygen atom that connectsthe alkyl group to the point of attachment: alkyl-O—. As for the alkylgroup, alkoxy groups can have any suitable number of carbon atoms, suchas C₁₋₆. Alkoxy groups include, for example, methoxy, ethoxy, propoxy,iso-propoxy, butoxy, 2-butoxy, iso-butoxy, sec-butoxy, tert-butoxy,pentoxy, hexoxy, etc.

“Halogen” refers to fluorine, chlorine, bromine, and iodine.

“Haloalkyl” refers to alkyl, as defined above, where some or all of thehydrogen atoms are replaced with halogen atoms. As for the alkyl group,haloalkyl groups can have any suitable number of carbon atoms, such asC₁₋₆, and include trifluoromethyl, fluoromethyl, etc.

The term “perfluoro” can be used to define a compound or radical whereall the hydrogens are replaced with fluorine. For example,perfluoromethane includes 1,1,1-trifluoromethyl.

“Haloalkoxy” refers to an alkoxy group where some or all of the hydrogenatoms are substituted with halogen atoms. As for the alkyl group,haloalkoxy groups can have any suitable number of carbon atoms, such asC₁₋₆. The alkoxy groups can be substituted with 1, 2, 3, or morehalogens. When all the hydrogens are replaced with a halogen, forexample by fluorine, the compounds are per-substituted, for example,perfluorinated. Haloalkoxy includes, but is not limited to,trifluoromethoxy, 2,2,2,-trifluoroethoxy, and perfluoroethoxy.

“Cycloalkyl” refers to a saturated or partially unsaturated, monocyclic,fused bicyclic, or bridged polycyclic ring assembly containing from 3 to12 ring atoms, or the number of atoms indicated. Cycloalkyl can includeany number of carbons, such as C₃₋₆, C₄₋₆, C₅₋₆, C₃₋₈, C₄₋₈, C₅₋₈, C₆₋₈,C₃₋₉, C₃₋₁₀, C₃₋₁₁, and C₃₋₁₂. Saturated monocyclic cycloalkyl ringsinclude, for example, cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl,and cyclooctyl. Saturated bicyclic and polycyclic cycloalkyl ringsinclude, for example, norbornane, [2.2.2] bicyclooctane,decahydronaphthalene, and adamantane. Cycloalkyl groups can also bepartially unsaturated, having one or more double or triple bonds in thering. Representative cycloalkyl groups that are partially unsaturatedinclude, but are not limited to, cyclobutene, cyclopentene, cyclohexene,cyclohexadiene (1,3- and 1,4-isomers), cycloheptene, cycloheptadiene,cyclooctene, cyclooctadiene (1,3-, 1,4- and 1,5-isomers), norbornene,and norbornadiene. When cycloalkyl is a saturated monocyclic C₃₋₈cycloalkyl, exemplary groups include, but are not limited to,cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, cycloheptyl, andcyclooctyl. When cycloalkyl is a saturated monocyclic C3-6 cycloalkyl,exemplary groups include, but are not limited to, cyclopropyl,cyclobutyl, cyclopentyl, and cyclohexyl.

“Heterocycloalkyl” refers to a saturated ring system having from 3 to 12ring members and from 1 to 4 heteroatoms of N, O, and S. Additionalheteroatoms can also be useful, including but not limited to, B, Al, Si,and P. The heteroatoms can also be oxidized, such as, but not limitedto, —S(O)— and —S(O)₂—. Heterocycloalkyl groups can include any numberof ring atoms, such as 3 to 6, 4 to 6, 5 to 6, 3 to 8, 4 to 8, 5 to 8, 6to 8, 3 to 9, 3 to 10, 3 to 11, or 3 to 12 ring members. Any suitablenumber of heteroatoms can be included in the heterocycloalkyl groups,such as 1, 2, 3, or 4, or 1 to 2, 1 to 3, 1 to 4, 2 to 3, 2 to 4, or 3to 4. The heterocycloalkyl group can include groups such as aziridine,azetidine, pyrrolidine, piperidine, azepane, azocane, quinuclidine,pyrazolidine, imidazolidine, piperazine (1,2-, 1,3- and 1,4-isomers),oxirane, oxetane, tetrahydrofuran, oxane (tetrahydropyran), oxepane,thiirane, thietane, thiolane (tetrahydrothiophene), thiane(tetrahydrothiopyran), oxazolidine, isoxalidine, thiazolidine,isothiazolidine, dioxolane, dithiolane, morpholine, thiomorpholine,dioxane, or dithiane. The heterocycloalkyl groups can also be fused toaromatic or non-aromatic ring systems to form members including, but notlimited to, indoline.

When heterocycloalkyl includes 3 to 8 ring members and 1 to 3heteroatoms, representative members include, but are not limited to,pyrrolidine, piperidine, tetrahydrofuran, oxane, tetrahydrothiophene,thiane, pyrazolidine, imidazolidine, piperazine, oxazolidine,isoxazolidine, thiazolidine, isothiazolidine, morpholine,thiomorpholine, dioxane and dithiane. Heterocycloalkyl can also form aring having 5 to 6 ring members and 1 to 2 heteroatoms, withrepresentative members including, but not limited to, pyrrolidine,piperidine, tetrahydrofuran, tetrahydrothiophene, pyrazolidine,imidazolidine, piperazine, oxazolidine, isoxazolidine, thiazolidine,isothiazolidine, and morpholine.

“Aryl” refers to an aromatic ring system having any suitable number ofring atoms and any suitable number of rings. Aryl groups can include anysuitable number of ring atoms, such as 6, 7, 8, 9, 10, 11, 12, 13, 14,15, or 16 ring atoms, as well as from 6 to 10, 6 to 12, or 6 to 14 ringmembers. Aryl groups can be monocyclic, fused to form bicyclic ortricyclic groups, or linked by a bond to form a biaryl group.Representative aryl groups include phenyl, naphthyl and biphenyl. Otheraryl groups include benzyl, that has a methylene linking group. Somearyl groups have from 6 to 12 ring members, such as phenyl, naphthyl, orbiphenyl. Other aryl groups have from 6 to 10 ring members, such asphenyl or naphthyl. Some other aryl groups have 6 ring members, such asphenyl. Aryl groups can be substituted or unsubstituted.

“Heteroaryl” refers to a monocyclic, fused bicyclic, or tricyclicaromatic ring assembly containing 5 to 16 ring atoms, where from 1 to 5of the ring atoms are a heteroatom such as N, O, or S. Additionalheteroatoms can also be useful, including but not limited to, B, Al, Si,and P. The heteroatoms can also be oxidized, such as, but not limitedto, N-oxide, —S(O)—, and —S(O)₂—. Heteroaryl groups can include anynumber of ring atoms, such as 3 to 6, 4 to 6, 5 to 6, 3 to 8, 4 to 8, 5to 8, 6 to 8, 3 to 9, 3 to 10, 3 to 11, or 3 to 12 ring members. Anysuitable number of heteroatoms can be included in the heteroaryl groups,such as 1, 2, 3, 4, or 5; or 1 to 2, 1 to 3, 1 to 4, 1 to 5, 2 to 3, 2to 4, 2 to 5, 3 to 4, or 3 to 5. Heteroaryl groups can have from 5 to 8ring members and from 1 to 4 heteroatoms, or from 5 to 8 ring membersand from 1 to 3 heteroatoms, or from 5 to 6 ring members and from 1 to 4heteroatoms, or from 5 to 6 ring members and from 1 to 3 heteroatoms.The heteroaryl group can include groups such as pyrrole, pyridine,imidazole, pyrazole, triazole, tetrazole, pyrazine, pyrimidine,pyridazine, triazine (1,2,3-, 1,2,4-, and 1,3,5-isomers), thiophene,furan, thiazole, isothiazole, oxazole, and isoxazole. The heteroarylgroups can also be fused to aromatic ring systems, such as a phenylring, to form members including, but not limited to, benzopyrroles suchas indole and isoindole, benzopyridines such as quinoline andisoquinoline, benzopyrazine (quinoxaline), benzopyrimidine(quinazoline), benzopyridazines such as phthalazine and cinnoline,benzothiophene, and benzofuran. Other heteroaryl groups includeheteroaryl rings linked by a bond, such as bipyridine. Heteroaryl groupscan be substituted or unsubstituted.

The heteroaryl groups can be linked via any position on the ring. Forexample, pyrrole includes 1-, 2-, and 3-pyrrole; pyridine includes 2-,3- and 4-pyridine; imidazole includes 1-, 2-, 4- and 5-imidazole;pyrazole includes 1-, 3-, 4- and 5-pyrazole; triazole includes 1-, 4-and 5-triazole; tetrazole includes 1- and 5-tetrazole; pyrimidineincludes 2-, 4-, 5- and 6-pyrimidine; pyridazine includes 3- and4-pyridazine; 1,2,3-triazine includes 4- and 5-triazine; 1,2,4-triazineincludes 3-, 5- and 6-triazine; 1,3,5-triazine includes 2-triazine;thiophene includes 2- and 3-thiophene; furan includes 2- and 3-furan;thiazole includes 2-, 4- and 5-thiazole; isothiazole includes 3-, 4- and5-isothiazole; oxazole includes 2-, 4- and 5-oxazole; isoxazole includes3-, 4- and 5-isoxazole; indole includes 1-, 2- and 3-indole; isoindoleincludes 1- and 2-isoindole; quinoline includes 2-, 3- and 4-quinoline;isoquinoline includes 1-, 3- and 4-isoquinoline; quinazoline includes 2-and 4-quinoazoline; cinnoline includes 3- and 4-cinnoline;benzothiophene includes 2- and 3-benzothiophene; and benzofuran includes2- and 3-benzofuran.

Some heteroaryl groups include those having from 5 to 10 ring membersand from 1 to 3 ring atoms including N, O, or S, such as pyrrole,pyridine, imidazole, pyrazole, triazole, pyrazine, pyrimidine,pyridazine, triazine (1,2,3-, 1,2,4- and 1,3,5-isomers), thiophene,furan, thiazole, isothiazole, oxazole, isoxazole, indole, isoindole,quinoline, isoquinoline, quinoxaline, quinazoline, phthalazine,cinnoline, benzothiophene, and benzofuran. Other heteroaryl groupsinclude those having from 5 to 8 ring members and from 1 to 3heteroatoms, such as pyrrole, pyridine, imidazole, pyrazole, triazole,pyrazine, pyrimidine, pyridazine, triazine (1,2,3-, 1,2,4- and1,3,5-isomers), thiophene, furan, thiazole, isothiazole, oxazole, andisoxazole. Some other heteroaryl groups include those having from 9 to12 ring members and from 1 to 3 heteroatoms, such as indole, isoindole,quinoline, isoquinoline, quinoxaline, quinazoline, phthalazine,cinnoline, benzothiophene, benzofuran and bipyridine. Still otherheteroaryl groups include those having from 5 to 6 ring members and from1 to 2 ring heteroatoms including N, O or S, such as pyrrole, pyridine,imidazole, pyrazole, pyrazine, pyrimidine, pyridazine, thiophene, furan,thiazole, isothiazole, oxazole, and isoxazole.

Some heteroaryl groups include from 5 to 10 ring members and onlynitrogen heteroatoms, such as pyrrole, pyridine, imidazole, pyrazole,triazole, pyrazine, pyrimidine, pyridazine, triazine (1,2,3-, 1,2,4- and1,3,5-isomers), indole, isoindole, quinoline, isoquinoline, quinoxaline,quinazoline, phthalazine, and cinnoline. Other heteroaryl groups includefrom 5 to 10 ring members and only oxygen heteroatoms, such as furan andbenzofuran. Some other heteroaryl groups include from 5 to 10 ringmembers and only sulfur heteroatoms, such as thiophene andbenzothiophene. Still other heteroaryl groups include from 5 to 10 ringmembers and at least two heteroatoms, such as imidazole, pyrazole,triazole, pyrazine, pyrimidine, pyridazine, triazine (1,2,3-, 1,2,4- and1,3,5-isomers), thiazole, isothiazole, oxazole, isoxazole, quinoxaline,quinazoline, phthalazine, and cinnoline.

“Heteroatoms” refers to O, S, or N.

“Salt” refers to acid or base salts of the compounds used in the methodsof the present invention. Illustrative examples ofpharmaceutically-acceptable salts are mineral acid (hydrochloric acid,hydrobromic acid, phosphoric acid, and the like) salts, organic acid(acetic acid, propionic acid, glutamic acid, citric acid, and the like)salts, and quaternary ammonium (methyl iodide, ethyl iodide, and thelike) salts. It is understood that the pharmaceutically-acceptable saltsare non-toxic. Additional information on suitablepharmaceutically-acceptable salts can be found in Remington'sPharmaceutical Sciences, 17th ed., Mack Publishing Company, Easton, Pa.,1985, which is incorporated herein by reference.

“Isomers” refers to compounds with the same chemical formula but whichare structurally distinguishable.

“Tautomer” refers to one of two or more structural isomers which existin equilibrium and which are readily converted from one form to another.

Descriptions of compounds of the present invention are limited byprinciples of chemical bonding known to those skilled in the art.Accordingly, where a group may be substituted by one or more of a numberof substituents, such substitutions are selected so as to comply withprinciples of chemical bonding and to produce compounds which are notinherently unstable—and/or would be known to one of ordinary skill inthe art as likely to be unstable under ambient conditions—such asaqueous, neutral, or physiological conditions.

“Pharmaceutically-acceptable excipient” and “pharmaceutically-acceptablecarrier” refer to a substance that aids the administration of an activeagent to—and absorption by—a subject and can be included in thecompositions of the present invention without causing a significantadverse toxicological effect on the patient. Non-limiting examples ofpharmaceutically-acceptable excipients include water, NaCl, normalsaline solutions, lactated Ringer's, normal sucrose, normal glucose,binders, fillers, disintegrants, lubricants, coatings, sweeteners,flavors and colors, and the like. One of ordinary skill in the art willrecognize that other pharmaceutical excipients are useful in the presentinvention.

C. Cervical Tumors

Cervical cancer is a malignant tumor within the cervix, or derived fromthe cervix. Cervical cancer is the fourth most-common cause of death inwomen world-wide. In the United States, well over 10,000 new cases areidentified each year. Patients suffering from cervical cancer may notexperience symptoms during the initial stages of the disease..Riskfactors for cervical cancer in women include: history of human papillomaviral (HPV) infection, smoking, and other factors. However, not allpatients in the currently recognized risk categories will developcervical cancers.

Cervical cancer symptoms include abnormal vaginal bleeding and pain inthe pelvic area. Cervical cancer may be, for example, a squamous cellcarcinoma, and adenocarcinoma, an adenosquamous carcinoma, a small cellcarcinoma, a neuroendocrine tumor, or other cancer type.

Visual screening of the cervix, often with the use of visual contrastagents such as acetic acid, is commonly performed during routine patientvisits, but the results are not definitive. Although the “Pap smear”test is used to screen for cervical cancer, but negative results fromthat screening test are often incorrect. Biopsies of cervical tissue maybe used to identify or diagnose cervical cancer. One or more of imagingbased methods, such as, magnetic resonance imaging (MRI), computedtomography (CT), X-ray, and positron emission tomography (PET) scan, orultrasonography (US), are often performed on subjects suspected ofhaving cervical cancer, e.g., based on exhibition of the relatedclinical symptoms. Results from these biopsies or imaging tests areoften combined with the patient's medical history, physical examinationand lab tests to provide accurate diagnosis as well as informationregarding the origin of the tumor.

The presence of cervical cancer, the type and stage of cervical cancercan be confirmed by histological analysis of the tumor performed by apathologist. Histology dictates many aspects of cervical cancer clinicaltreatment, management, and prognosis.

D. Cancerous Tumors

The methods disclosed herein are applicable for treating canceroustumors. After the diagnosis of cervical cancer, the tumor can beevaluated to determine stage and other tumor characteristics.

E. Glucocorticoid Receptor Modulators (GRM)

Generally, treatment of a cancerous tumor can be provided byadministering an effective amount of a chemotherapeutic agent incombination with an effective amount of a SGRM of any chemical structureor mechanism of action. Provided herein, are classes of exemplary GRMsand specific members of such classes. However, one of skill in the artwill readily recognize other related or unrelated SGRMs that can beemployed in the treatment methods described herein.

Non-Steroidal Anti-Glucocorticoid Receptors Modulators

Provided herein, are classes of exemplary non-steroidal glucocorticoidreceptor modulators (GRMs) and specific members of such classes that canbe used for the method disclosed herein. However, one of skill in theart will readily recognize other related or unrelated glucocorticoidreceptor modulators that can be employed in the treatment methodsdescribed herein. These include synthetic mimetics and analogs ofproteins, including partially peptidic, pseudopeptidic and non-peptidicmolecular entities. For example, oligomeric peptidomimetics useful inthe invention include (α-β-unsaturated) peptidosulfonamides,N-substituted glycine derivatives, oligo carbamates, oligo ureapeptidomimetics, hydrazinopeptides, oligosulfones and the like (See,e.g., Amour, Int. J. Pept. Protein Res. 43:297-304, 1994; de Bont,Bioorganic & Medicinal Chem. 4:667-672, 1996).

Examples of non-steroidal GR modulators include the GR antagonistcompounds disclosed in U.S. Pat. Nos. 5,696,127; 6,570,020; and6,051,573; the GR antagonist compounds disclosed in US PatentApplication 20020077356, the glucocorticoid receptor antagonistsdisclosed in Bradley et al., J. Med. Chem. 45, 2417-2424 (2002), e.g.,4α(S)-benzyl-2(R)-chloroethynyl-1,2,3,4,4α,9,10,10α(R)-octahydro-phenanthrene-2,7-diol(“CP 394531”) and4α(S)-benzyl-2(R)-prop-1-ynyl-1,2,3,4,4α,9,10,10α(R)-octahydro-phenanthrene-2,7-diol(“CP 409069”); and the compounds disclosed in PCT InternationalApplication No. WO 96/19458, which describes non-steroidal compoundswhich are high-affinity, highly selective antagonists for steroidreceptors, such as 6-substituted-1,2-dihydro-N-protected-quinolines.

For additional compounds that can be utilized in the methods of theinvention and methods of identifying and making such compounds, see U.S.Pat. No. 4,296,206 (see above); U.S. Pat. No. 4,386,085 (see above);U.S. Pat. Nos. 4,447,424; 4,477,445; 4,519,946; 4,540,686; 4,547,493;4,634,695; 4,634,696; 4,753,932; 4,774,236; 4,808,710; 4,814,327;4,829,060; 4,861,763; 4,912,097; 4,921,638; 4,943,566; 4,954,490;4,978,657; 5,006,518; 5,043,332; 5,064,822; 5,073,548; 5,089,488;5,089,635; 5,093,507; 5,095,010; 5,095,129; 5,132,299; 5,166,146;5,166,199; 5,173,405; 5,276,023; 5,380,839; 5,348,729; 5,426,102;5,439,913; and 5,616,458; and WO 96/19458, which describes non-steroidalcompounds which are high-affinity, highly selective modulators(antagonists) for steroid receptors, such as 6-substituted-1,2-dihydroN-1 protected quinolines.

In some embodiments, the combination therapy for treating cancerinvolves a GRM having a fused azadecalin backbone, a heteroaryl ketonefused azadecalin backbone, or an octahydro fused azadecalin backbone.

Exemplary GRMs having a fused azadecalin backbone include thosedescribed in U.S. Pat. Nos. 7,928,237; 8,461,172; and 8,557,839 and canbe prepared as disclosed therein. These patents are incorporated hereinin their entirety. In some cases, the GRM having a fused azadecalinbackbone has the following structure:

wherein

L¹ and L² are members independently selected from a bond andunsubstituted alkylene;

R¹ is a member selected from unsubstituted alkyl, unsubstitutedheteroalkyl, unsubstituted heterocycloalkyl, —OR^(1A), —NR^(1C)R^(1D),—C(O)NR^(1C)R^(1D), and —C(O)OR^(1A), wherein

R^(1A) is a member selected from hydrogen, unsubstituted alkyl andunsubstituted heteroalkyl,

R^(1C) and R^(1D) are members independently selected from unsubstitutedalkyl and unsubstituted heteroalkyl,

wherein R^(1C) and R^(1D) are optionally joined to form an unsubstitutedring with the nitrogen to which they are attached, wherein said ringoptionally comprises an additional ring nitrogen;

R² has the formula:

wherein

R^(2G) is a member selected from hydrogen, halogen, unsubstituted alkyl,unsubstituted heteroalkyl, unsubstituted cycloalkyl, unsubstitutedheterocycloalkyl, —CN, and —CF₃;

J is phenyl;

t is an integer from 0 to 5;

X is —S(O₂)—; and

R⁵ is phenyl optionally substituted with 1-5 R^(5A) groups, wherein

R^(5A) is a member selected from hydrogen, halogen, —OR^(5A1),—S(O₂)NR^(5A2)R^(5A3), —CN, and unsubstituted alkyl, wherein

R^(5A1) is a member selected from hydrogen and unsubstituted alkyl, and

R^(5A2) and R^(5A3) are members independently selected from hydrogen andunsubstituted alkyl,

or salts and isomers thereof.

Exemplary GRMs having a heteroaryl ketone fused azadecalin backboneinclude those described in U.S. 2014/0038926, which can be prepared asdisclosed therein, and is incorporated herein in its entirety. In somecases, the GRM having a heteroaryl ketone fused azadecalin backbone hasthe following structure:

wherein

R¹ is a heteroaryl ring having from 5 to 6 ring members and from 1 to 4heteroatoms each independently selected from the group consisting of N,O and S, optionally substituted with 1-4 groups each independentlyselected from R^(1a);

each R^(1a) is independently selected from the group consisting ofhydrogen, C₁₋₆ alkyl, halogen, C₁₋₆ haloalkyl, C₁₋₆ alkoxy, C₁₋₆haloalkoxy, —CN, N-oxide, C₃₋₈ cycloalkyl, and C₃₋₈ heterocycloalkyl;

ring J is selected from the group consisting of a cycloalkyl ring, aheterocycloalkyl ring, an aryl ring and a heteroaryl ring, wherein theheterocycloalkyl and heteroaryl rings have from 5 to 6 ring members andfrom 1 to 4 heteroatoms each independently selected from the groupconsisting of N, O and S;

each R² is independently selected from the group consisting of hydrogen,C₁₋₆ alkyl, halogen, C₁₋₆ haloalkyl, C₁₋₆ alkoxy, C₁₋₆ haloalkoxy, C₁₋₆alkyl-C₁₋₆ alkoxy, —CN, —OH, —NR^(2a)R^(2b), —C(O)R^(2a), —C(O)OR^(2a),—C(O)NR^(2a)R^(2b), —SR^(2a), —S(O)R^(2a), —S(O)₂R^(2a), C₃₋₈cycloalkyl, and C₃₋₈ heterocycloalkyl, wherein the heterocycloalkylgroups are optionally substituted with 1-4 R^(2c) groups;

alternatively, two R² groups linked to the same carbon are combined toform an oxo group (═O);

alternatively, two R² groups are combined to form a heterocycloalkylring having from 5 to 6 ring members and from 1 to 3 heteroatoms eachindependently selected from the group consisting of N, O and S, whereinthe heterocycloalkyl ring is optionally substituted with from 1 to 3R^(2d) groups;

R^(2a) and R^(2b) are each independently selected from the groupconsisting of hydrogen and C₁₋₆ alkyl;

each R^(2c) is independently selected from the group consisting ofhydrogen, halogen, hydroxy, C₁₋₆ alkoxy, C₁₋₆ haloalkoxy, —CN, and—NR^(2a)R^(2b);

each R^(2d) is independently selected from the group consisting ofhydrogen and C₁₋₆ alkyl, or two R^(2d) groups attached to the same ringatom are combined to form (═O);

R³ is selected from the group consisting of phenyl and pyridyl, eachoptionally substituted with 1-4 R^(3a) groups;

each R^(3a) is independently selected from the group consisting ofhydrogen, halogen, and C₁₋₆ haloalkyl; and

subscript n is an integer from 0 to 3;

or salts and isomers thereof.

Exemplary GRMs having an octahydro fused azadecalin backbone includethose described in U.S. Pat. Pub. No. 20150148341 filed on Nov. 21, 2014and can be prepared as described therein. The disclosure of U.S. Pat.Pub. No. 20150148341 is incorporated herein in their entirety. In somecases, the GRM having an octahydro fused azadecalin backbone has thefollowing structure:

wherein

R¹ is a heteroaryl ring having from 5 to 6 ring members and from 1 to 4heteroatoms each independently selected from the group consisting of N,O and S, optionally substituted with 1-4 groups each independentlyselected from R^(1a);

each R^(1a) is independently selected from the group consisting ofhydrogen, C₁₋₆ alkyl, halogen, C₁₋₆ haloalkyl, C₁₋₆ alkoxy, C₁₋₆haloalkoxy, N-oxide, and C₃₋₈ cycloalkyl;

ring J is selected from the group consisting of an aryl ring and aheteroaryl ring having from 5 to 6 ring members and from 1 to 4heteroatoms each independently selected from the group consisting of N,O and S;

each R² is independently selected from the group consisting of hydrogen,C₁₋₆ alkyl, halogen, C₁₋₆ haloalkyl, C₁₋₆ alkoxy, C₁₋₆ haloalkoxy, C₁₋₆alkyl-C₁₋₆ alkoxy, —CN, —OH, —NR^(2a)R^(2b), —C(O)R^(2a), —C(O)OR^(2a),—C(O)NR^(2a)R^(2b), —SR^(2a), —S(O)R^(2a), —S(O)₂R^(2a), C₃₋₈cycloalkyl, and C₃₋₈ heterocycloalkyl having from 1 to 3 heteroatomseach independently selected from the group consisting of N, O and S;

alternatively, two R² groups on adjacent ring atoms are combined to forma heterocycloalkyl ring having from 5 to 6 ring members and from 1 to 3heteroatoms each independently selected from the group consisting of N,O and S, wherein the heterocycloalkyl ring is optionally substitutedwith from 1 to 3 R^(2c) groups;

R^(2a), R^(2b) and R^(2c) are each independently selected from the groupconsisting of hydrogen and C₁₋₆ alkyl;

each R^(3a) is independently halogen; and

subscript n is an integer from 0 to 3;

or salts and isomers thereof.

F. Identifying Selective Glucocorticoid Receptor Modulators (SGRMS)

To determine whether a test compound is a SGRM, the compound is firstsubjected to assays to measure its ability to bind to the GR and inhibitGR-mediated activities, which determines whether the compound is aglucocorticoid receptor modulator. The compound, if confirmed to be aglucocorticoid receptor modulator, is then subjected to a selectivitytest to determine whether the compound can bind specifically to GR ascompared to non GR proteins, such as the estrogen receptor, theprogesterone receptor, the androgen receptor, or the mineralocorticoidreceptor. In one embodiment, a SGRM binds to GR at a substantiallyhigher affinity, e.g., at least 10 times higher affinity, than to non-GRproteins. A SGRM may exhibit a 100 fold, 1000 fold or greaterselectivity for binding to GR relative to binding to non GR proteins.

i. Binding

A test compounds' ability to bind to the glucocorticoid receptor can bemeasured using a variety of assays, for example, by screening for theability of the test compound to compete with a glucocorticoid receptorligand, such as dexamethasone, for binding to the glucocorticoidreceptor. Those of skill in the art will recognize that there are anumber of ways to perform such competitive binding assays. In someembodiments, the glucocorticoid receptor is pre-incubated with a labeledglucocorticoid receptor ligand and then contacted with a test compound.This type of competitive binding assay may also be referred to herein asa binding displacement assay. A decrease of the quantity of labeledligand bound to glucocorticoid receptor indicates that the test compoundbinds to the glucocorticoid receptor. In some cases, the labeled ligandis a fluorescently labeled compound (e.g., a fluorescently labeledsteroid or steroid analog). Alternatively, the binding of a testcompound to the glucocorticoid receptor can be measured directly with alabeled test compound. This latter type of assay is called a directbinding assay.

Both direct binding assays and competitive binding assays can be used ina variety of different formats. The formats may be similar to those usedin immunoassays and receptor binding assays. For a description ofdifferent formats for binding assays, including competitive bindingassays and direct binding assays, see Basic and Clinical Immunology 7thEdition (D. Stites and A. Terr ed.) 1991; Enzyme Immunoassay, E. T.Maggio, ed., CRC Press, Boca Raton, Fl. (1980); and “Practice and Theoryof Enzyme Immunoassays,” P. Tijssen, Laboratory Techniques inBiochemistry and Molecular Biology, Elsevier Science Publishers B.V.Amsterdam (1985), each of which is incorporated herein by reference.

In solid phase competitive binding assays, for example, the samplecompound can compete with a labeled analyte for specific binding siteson a binding agent bound to a solid surface. In this type of format, thelabeled analyte can be a glucocorticoid receptor ligand and the bindingagent can be glucocorticoid receptor bound to a solid phase.Alternatively, the labeled analyte can be labeled glucocorticoidreceptor and the binding agent can be a solid phase glucocorticoidreceptor ligand. The concentration of labeled analyte bound to thecapture agent is inversely proportional to the ability of a testcompound to compete in the binding assay.

Alternatively, the competitive binding assay may be conducted in theliquid phase, and any of a variety of techniques known in the art may beused to separate the bound labeled protein from the unbound labeledprotein. For example, several procedures have been developed fordistinguishing between bound ligand and excess bound ligand or betweenbound test compound and the excess unbound test compound. These includeidentification of the bound complex by sedimentation in sucrosegradients, gel electrophoresis, or gel isoelectric focusing;precipitation of the receptor-ligand complex with protamine sulfate oradsorption on hydroxylapatite; and the removal of unbound compounds orligands by adsorption on dextran-coated charcoal (DCC) or binding toimmobilized antibody. Following separation, the amount of bound ligandor test compound is determined.

Alternatively, a homogenous binding assay may be performed in which aseparation step is not needed. For example, a label on theglucocorticoid receptor may be altered by the binding of theglucocorticoid receptor to its ligand or test compound. This alterationin the labeled glucocorticoid receptor results in a decrease or increasein the signal emitted by label, so that measurement of the label at theend of the binding assay allows for detection or quantitation of theglucocorticoid receptor in the bound state. A wide variety of labels maybe used. The component may be labeled by any one of several methods.Useful radioactive labels include those incorporating ₃H, ¹²⁵I, ³⁵S,¹⁴C, or ³²P. Useful non-radioactive labels include those incorporatingfluorophores, chemiluminescent agents, phosphorescent agents,electrochemiluminescent agents, and the like. Fluorescent agents areespecially useful in analytical techniques that are used to detectshifts in protein structure such as fluorescence anisotropy and/orfluorescence polarization. The choice of label depends on sensitivityrequired, ease of conjugation with the compound, stability requirements,and available instrumentation. For a review of various labeling orsignal producing systems which may be used, see U.S. Pat. No. 4,391,904,which is incorporated herein by reference in its entirety for allpurposes. The label may be coupled directly or indirectly to the desiredcomponent of the assay according to methods well known in the art. Insome cases, a test compound is contacted with a GR in the presence of afluorescently labeled ligand (e.g., a steroid or steroid analog) with aknown affinity for the GR, and the quantity of bound and free labeledligand is estimated by measuring the fluorescence polarization of thelabeled ligand.

ii. Activity

1) HepG2 Tyrosine Aminotransferase (TAT) Assay

Compounds that have demonstrated the desired binding affinity to GR aretested for their activity in inhibiting GR mediated activities. Thecompounds are typically subject to a Tyrosine Aminotransferase Assay(TAT assay), which assesses the ability of a test compound to inhibitthe induction of tyrosine aminotransferase activity by dexamethasone.See Example 1. GR modulators that are suitable for the method disclosedherein have an IC₅₀ (half maximal inhibition concentration) of less than10 micromolar. Other assays, including but not limited to thosedescribed below, can also be deployed to confirm the GR modulationactivity of the compounds.

2) Cell-Based Assays

Cell-based assays which involve whole cells or cell fractions containingglucocorticoid receptors can also be used to assay for a test compound'sbinding or modulation of activity of the glucocorticoid receptor.Exemplary cell types that can be used according to the methods of theinvention include, e.g., any mammalian cells including leukocytes suchas neutrophils, monocytes, macrophages, eosinophils, basophils, mastcells, and lymphocytes, such as T cells and B cells, leukemia cells,Burkitt's lymphoma cells, tumor cells (including mouse mammary tumorvirus cells), endothelial cells, fibroblasts, cardiac cells, musclecells, breast tumor cells, ovarian cancer carcinomas, cervicalcarcinomas, glioblastomas, liver cells, kidney cells, and neuronalcells, as well as fungal cells, including yeast. Cells can be primarycells or tumor cells or other types of immortal cell lines. Of course,the glucocorticoid receptor can be expressed in cells that do notexpress an endogenous version of the glucocorticoid receptor.

In some cases, fragments of the glucocorticoid receptor, as well asprotein fusions, can be used for screening. When molecules that competefor binding with the glucocorticoid receptor ligands are desired, the GRfragments used are fragments capable of binding the ligands (e.g.,dexamethasone). Alternatively, any fragment of GR can be used as atarget to identify molecules that bind the glucocorticoid receptor.Glucocorticoid receptor fragments can include any fragment of, e.g., atleast 20, 30, 40, 50 amino acids up to a protein containing all but oneamino acid of glucocorticoid receptor.

In some embodiments, a reduction in signaling triggered byglucocorticoid receptor activation is used to identify glucocorticoidreceptor modulators. Signaling activity of the glucocorticoid receptorcan be determined in many ways. For example, downstream molecular eventscan be monitored to determine signaling activity. Downstream eventsinclude those activities or manifestations that occur as a result ofstimulation of a glucocorticoid receptor . Exemplary downstream eventsuseful in the functional evaluation of transcriptional activation andantagonism in unaltered cells include upregulation of a number ofglucocorticoid response element (GRE)-dependent genes (PEPCK, tyrosineamino transferase, aromatase). In addition, specific cell typessusceptible to GR activation may be used, such as osteocalcin expressionin osteoblasts which is downregulated by glucocorticoids; primaryhepatocytes which exhibit glucocorticoid mediated upregulation of PEPCKand glucose-6-phosphate (G-6-Pase)). GRE-mediated gene expression hasalso been demonstrated in transfected cell lines using well-knownGRE-regulated sequences (e.g., the mouse mammary tumor virus promoter(MMTV) transfected upstream of a reporter gene construct). Examples ofuseful reporter gene constructs include luciferase (luc), alkalinephosphatase (ALP) and chloramphenicol acetyl transferase (CAT). Thefunctional evaluation of transcriptional repression can be carried outin cell lines such as monocytes or human skin fibroblasts. Usefulfunctional assays include those that measure IL-1beta stimulated IL-6expression; the downregulation of collagenase, cyclooxygenase-2 andvarious chemokines (MCP-1, RANTES); LPS stimulated cytokine release,e.g., TNFα; or expression of genes regulated by NFkB or AP-1transcription factors in transfected cell-lines.

Compounds that are tested in whole-cell assays can also be tested in acytotoxicity assay. Cytotoxicity assays are used to determine the extentto which a perceived effect is due to non-glucocorticoid receptorbinding cellular effects. In an exemplary embodiment, the cytotoxicityassay includes contacting a constitutively active cell with the testcompound. Any decrease in cellular activity indicates a cytotoxiceffect.

3) Additional Assays

Further illustrative of the many assays which can be used to identifycompositions utilized in the methods of the invention, are assays basedon glucocorticoid activities in vivo. For example, assays that assessthe ability of a putative GR modulator to inhibit uptake of 3H-thymidineinto DNA in cells which are stimulated by glucocorticoids can be used.Alternatively, the putative GR modulator can complete with3H-dexamethasone for binding to a hepatoma tissue culture GR (see, e.g.,Choi, et al., Steroids 57:313-318, 1992). As another example, theability of a putative GR modulator to block nuclear binding of3H-dexamethasone-GR complex can be used (Alexandrova et al., J. SteroidBiochem. Mol. Biol. 41:723-725, 1992). To further identify putative GRmodulators, kinetic assays able to discriminate between glucocorticoidagonists and modulators by means of receptor-binding kinetics can alsobe used (as described in Jones, Biochem 1 204:721-729, 1982).

In another illustrative example, the assay described by Daune, Molec.Pharm. 13:948-955, 1977; and in U.S. Pat. No. 4,386,085, can be used toidentify anti-glucocorticoid activity. Briefly, the thymocytes ofadrenalectomized rats are incubated in nutritive medium containingdexamethasone with the test compound (the putative GR modulator) atvarying concentrations. ³H-uridine is added to the cell culture, whichis further incubated, and the extent of incorporation of radiolabel intopolynucleotide is measured. Glucocorticoid agonists decrease the amountof ³H-uridine incorporated. Thus, a GR modulator will oppose thiseffect.

iii. Selectivity

The GR modulators selected above are then subject to a selectivity assayto determine whether they are SGRMs. Typically, selectivity assaysinclude testing a compound that binds glucocorticoid receptor in vitrofor the degree of binding to non-glucocorticoid receptor proteins.Selectivity assays may be performed in vitro or in cell based systems,as described above. Binding may be tested against any appropriatenon-glucocorticoid receptor protein, including antibodies, receptors,enzymes, and the like. In an exemplary embodiment, thenon-glucocorticoid receptor binding protein is a cell-surface receptoror nuclear receptor. In another exemplary embodiment, thenon-glucocorticoid receptor protein is a steroid receptor, such asestrogen receptor, progesterone receptor, androgen receptor, ormineralocorticoid receptor.

The selectivity of the antagonist for the GR relative to the MR can bemeasured using a variety of assays known to those of skill in the art.For example, specific antagonists can be identified by measuring theability of the antagonist to bind to the GR compared to the MR (see,e.g., U.S. Pat. Nos. 5,606,021; 5,696,127; 5,215,916; 5,071,773). Suchan analysis can be performed using either a direct binding assay or byassessing competitive binding to the purified GR or MR in the presenceof a known ligand. In an exemplary assay, cells that stably express theglucocorticoid receptor or mineralocorticoid receptor (see, e.g., U.S.Pat. No. 5,606,021) at high levels are used as a source of purifiedreceptor. The affinity of the ligandfor the receptor is then directlymeasured. Those GR modulators that exhibit at least a 10 fold, 100-foldhigher affinity, often 1000-fold, for the GR relative to the MR are thenselected for use in the methods of the invention.

The selectivity assay may also include assaying the ability to inhibitGR-mediated activities, but not MR-mediated activities. One method ofidentifying such a GR-specific modulator is to assess the ability of anantagonist to prevent activation of reporter constructs usingtransfection assays (see, e.g., Bocquel et al, J. Steroid Biochem Molec.Biol. 45:205-215, 1993; U.S. Pat. Nos. 5,606,021, 5,929,058). In anexemplary transfection assay, an expression plasmid encoding thereceptor and a reporter plasmid containing a reporter gene linked toreceptor-specific regulatory elements are cotransfected into suitablereceptor-negative host cells. The transfected host cells are thencultured in the presence and absence of a hormone, such as cortisol oran analog thereof, able to activate the hormone responsivepromoter/enhancer element of the reporter plasmid. Next the transfectedand cultured host cells are monitored for induction (i.e., the presence)of the product of the reporter gene sequence. Finally, the expressionand/or steroid binding-capacity of the hormone receptor protein (codedfor by the receptor DNA sequence on the expression plasmid and producedin the transfected and cultured host cells), is measured by determiningthe activity of the reporter gene in the presence and absence of anantagonist. The antagonist activity of a compound may be determined incomparison to known antagonists of the GR and MR receptors (see, e.g.,U.S. Pat. No. 5,696,127). Efficacy is then reported as the percentmaximal response observed for each compound relative to a referenceantagonist compound. GR modulators that exhibits at least a 100-fold,often 1000-fold or greater, activity towards the GR relative to the MR,PR, or AR are then selected for use in the methods disclosed herein.

An exemplar SGRM that can be used in the methods disclosed herein isCORT 108297, i.e.,(R)-(4a-ethoxymethyl-1-(4-fluorophenyl)-6-(4-trifluoromethyl-benzenesulfonyl)-4,4a,5,6,7,8-hexahydro-1H,1,2,6-triaza-cyclopenta[b]naphthalene,which has the following structure:

An exemplar SGRM that can be used in the methods disclosed herein isCORT 125134, i.e.,(R)-(1-(4-fluorophenyl)-6-((1-methyl-1H-pyrazol-4-yl)sulfonyl)-4,4a,5,6,7,8-hexahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone,which has the following structure:

Another exemplar SGRM that can be used in the methods disclosed hereinis CORT 125281, i.e., ((4aR,8aS)-1-(4-fluorophenyl)-6-((2-methyl-2H-1,2,3-triazol-4-yl)sulfonyl)-4,4a,5, 6,7, 8, 8a,9-octahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone,which has the following structure:

G. Pharmaceutical Compositions and Administration

In some embodiments, the present invention provides a pharmaceuticalcomposition including a pharmaceutically acceptable excipient and aSGRM.

SGRMs can be prepared and administered in a wide variety of oral,parenteral and topical dosage forms. Oral preparations include tablets,pills, powder, dragees, capsules, liquids, lozenges, gels, syrups,slurries, suspensions, etc., suitable for ingestion by the patient.SGRMs can also be administered by injection, that is, intravenously,intramuscularly, intracutaneously, subcutaneously, intraduodenally, orintraperitoneally. Also, SGRMs can be administered by inhalation, forexample, intranasally. Additionally, SGRMs can be administeredtransdermally.

Accordingly, the present invention also provides pharmaceuticalcompositions including a pharmaceutically acceptable carrier orexcipient and a SGRM.

For preparing pharmaceutical compositions from SGRMs, pharmaceuticallyacceptable carriers can be either solid or liquid. Solid formpreparations include powders, tablets, pills, capsules, cachets,suppositories, and dispersible granules. A solid carrier can be one ormore substances, which may also act as diluents, flavoring agents,binders, preservatives, tablet disintegrating agents, or anencapsulating material. Details on techniques for formulation andadministration are well described in the scientific and patentliterature, see, e.g., the latest edition of Remington's PharmaceuticalSciences, Maack Publishing Co, Easton PA (“Remington's”).

In powders, the carrier is a finely divided solid, which is in a mixturewith the finely divided active component, a SGRM. In tablets, the activecomponent is mixed with the carrier having the necessary bindingproperties in suitable proportions and compacted in the shape and sizedesired.

The powders and tablets preferably contain from 5% or 10% to 70% of theactive compound. Suitable carriers are magnesium carbonate, magnesiumstearate, talc, sugar, lactose, pectin, dextrin, starch, gelatin,tragacanth, methylcellulose, sodium carboxymethylcellulose, a lowmelting wax, cocoa butter, and the like. The term “preparation” isintended to include the formulation of the active compound withencapsulating material as a carrier providing a capsule in which theactive component with or without other carriers, is surrounded by acarrier, which is thus in association with it. Similarly, cachets andlozenges are included. Tablets, powders, capsules, pills, cachets, andlozenges can be used as solid dosage forms suitable for oraladministration.

Suitable solid excipients are carbohydrate or protein fillers include,but are not limited to sugars, including lactose, sucrose, mannitol, orsorbitol; starch from corn, wheat, rice, potato, or other plants;cellulose such as methyl cellulose, hydroxypropylmethyl-cellulose, orsodium carboxymethylcellulose; and gums including arabic and tragacanth;as well as proteins such as gelatin and collagen. If desired,disintegrating or solubilizing agents may be added, such as thecross-linked polyvinyl pyrrolidone, agar, alginic acid, or a saltthereof, such as sodium alginate.

Dragee cores are provided with suitable coatings such as concentratedsugar solutions, which may also contain gum arabic, talc,polyvinylpyrrolidone, carbopol gel, polyethylene glycol, and/or titaniumdioxide, lacquer solutions, and suitable organic solvents or solventmixtures. Dyestuffs or pigments may be added to the tablets or drageecoatings for product identification or to characterize the quantity ofactive compound (i.e., dosage). Pharmaceutical preparations of theinvention can also be used orally using, for example, push-fit capsulesmade of gelatin, as well as soft, sealed capsules made of gelatin and acoating such as glycerol or sorbitol. Push-fit capsules can contain GRmodulator mixed with a filler or binders such as lactose or starches,lubricants such as talc or magnesium stearate, and, optionally,stabilizers. In soft capsules, the GR modulator compounds may bedissolved or suspended in suitable liquids, such as fatty oils, liquidparaffin, or liquid polyethylene glycol with or without stabilizers.

Liquid form preparations include solutions, suspensions, and emulsions,for example, water or water/propylene glycol solutions. For parenteralinjection, liquid preparations can be formulated in solution in aqueouspolyethylene glycol solution.

Aqueous solutions suitable for oral use can be prepared by dissolvingthe active component in water and adding suitable colorants, flavors,stabilizers, and thickening agents as desired. Aqueous suspensionssuitable for oral use can be made by dispersing the finely dividedactive component in water with viscous material, such as natural orsynthetic gums, resins, methylcellulose, sodium carboxymethylcellulose,hydroxypropylmethylcellulose, sodium alginate, polyvinylpyrrolidone, gumtragacanth and gum acacia, and dispersing or wetting agents such as anaturally occurring phosphatide (e.g., lecithin), a condensation productof an alkylene oxide with a fatty acid (e.g., polyoxyethylene stearate),a condensation product of ethylene oxide with a long chain aliphaticalcohol (e.g., heptadecaethylene oxycetanol), a condensation product ofethylene oxide with a partial ester derived from a fatty acid and ahexitol (e.g., polyoxyethylene sorbitol mono-oleate), or a condensationproduct of ethylene oxide with a partial ester derived from fatty acidand a hexitol anhydride (e.g., polyoxyethylene sorbitan mono-oleate).The aqueous suspension can also contain one or more preservatives suchas ethyl or n-propyl p-hydroxybenzoate, one or more coloring agents, oneor more flavoring agents and one or more sweetening agents, such assucrose, aspartame or saccharin. Formulations can be adjusted forosmolarity.

Also included are solid form preparations, which are intended to beconverted, shortly before use, to liquid form preparations for oraladministration. Such liquid forms include solutions, suspensions, andemulsions. These preparations may contain, in addition to the activecomponent, colorants, flavors, stabilizers, buffers, artificial andnatural sweeteners, dispersants, thickeners, solubilizing agents, andthe like.

Oil suspensions can be formulated by suspending a SGRM in a vegetableoil, such as arachis oil, olive oil, sesame oil or coconut oil, or in amineral oil such as liquid paraffin; or a mixture of these. The oilsuspensions can contain a thickening agent, such as beeswax, hardparaffin or cetyl alcohol. Sweetening agents can be added to provide apalatable oral preparation, such as glycerol, sorbitol or sucrose. Theseformulations can be preserved by the addition of an antioxidant such asascorbic acid. As an example of an injectable oil vehicle, see Minto, J.Pharmacol. Exp. Ther. 281:93-102, 1997. The pharmaceutical formulationsof the invention can also be in the form of oil-in-water emulsions. Theoily phase can be a vegetable oil or a mineral oil, described above, ora mixture of these. Suitable emulsifying agents includenaturally-occurring gums, such as gum acacia and gum tragacanth,naturally occurring phosphatides, such as soybean lecithin, esters orpartial esters derived from fatty acids and hexitol anhydrides, such assorbitan mono-oleate, and condensation products of these partial esterswith ethylene oxide, such as polyoxyethylene sorbitan mono-oleate. Theemulsion can also contain sweetening agents and flavoring agents, as inthe formulation of syrups and elixirs. Such formulations can alsocontain a demulcent, a preservative, or a coloring agent.

SGRMs can be delivered by transdermally, by a topical route, formulatedas applicator sticks, solutions, suspensions, emulsions, gels, creams,ointments, pastes, jellies, paints, powders, and aerosols.

SGRMs can also be delivered as microspheres for slow release in thebody. For example, microspheres can be administered via intradermalinjection of drug-containing microspheres, which slowly releasesubcutaneously (see Rao, J. Biomater Sci. Polym. Ed. 7:623-645, 1995; asbiodegradable and injectable gel formulations (see, e.g., Gao Pharm.Res. 12:857-863, 1995); or, as microspheres for oral administration(see, e.g., Eyles, J. Pharm. Pharmacol. 49:669-674, 1997). Bothtransdermal and intradermal routes afford constant delivery for weeks ormonths.

The pharmaceutical formulations of the invention can be provided as asalt and can be formed with many acids, including but not limited tohydrochloric, sulfuric, acetic, lactic, tartaric, malic, succinic, etc.Salts tend to be more soluble in aqueous or other protonic solvents thatare the corresponding free base forms. In other cases, the preparationmay be a lyophilized powder in 1 mM-50 mM histidine, 0.1%-2% sucrose,2%-7% mannitol at a pH range of 4.5 to 5.5, that is combined with bufferprior to use

In another embodiment, the formulations of the invention can bedelivered by the use of liposomes which fuse with the cellular membraneor are endocytosed, i.e., by employing ligands attached to the liposome,or attached directly to the oligonucleotide, that bind to surfacemembrane protein receptors of the cell resulting in endocytosis. Byusing liposomes, particularly where the liposome surface carries ligandsspecific for target cells, or are otherwise preferentially directed to aspecific organ, one can focus the delivery of the GR modulator into thetarget cells in vivo. (See, e.g., Al-Muhammed, J. Microencapsul.13:293-306, 1996; Chonn, Curr. Opin. Biotechnol. 6:698-708, 1995; Ostro,Am. J. Hosp. Pharm. 46:1576-1587, 1989).

The pharmaceutical preparation is preferably in unit dosage form. Insuch form the preparation is subdivided into unit doses containingappropriate quantities of the active component, a GRM. The unit dosageform can be a packaged preparation, the package containing discretequantities of preparation, such as packeted tablets, capsules, andpowders in vials or ampoules. Also, the unit dosage form can be acapsule, tablet, cachet, or lozenge itself, or it can be the appropriatenumber of any of these in packaged form.

The quantity of active component in a unit dose preparation may bevaried or adjusted from 0.1 mg to 10000 mg, more typically 1.0 mg to6000 mg, most typically 50 mg to 500 mg. Suitable dosages also includeabout 1 mg, 5, 10, 20, 30, 40, 50, 60, 70, 80, 90, 100, 200, 300, 400,500, 600, 700, 800, 900, 1000, 1100, 1200, 1300, 1400, 1500, 1600, 1700,1800, 1900, or 2000 mg, according to the particular application and thepotency of the active component. The composition can, if desired, alsocontain other compatible therapeutic agents.

Single or multiple administrations of formulations can be administereddepending on the dosage and frequency as required and tolerated by thepatient. The formulations should provide a sufficient quantity of activeagent to effectively treat the disease state. Thus, in one embodiment,the pharmaceutical formulation for oral administration of a GRM is in adaily amount of between about 0.01 to about 150 mg per kilogram of bodyweight per day (mg/kg/day). In some embodiments, the daily amount isfrom about 1.0 to 100 mg/kg/day, 5 to 50 mg/kg/day, 10 to 30 mg/kg/day,and 10 to 20 mg/kg/day. Lower dosages can be used, particularly when thedrug is administered to an anatomically secluded site, such as thecerebral spinal fluid (CSF) space, in contrast to administration orally,into the blood stream, into a body cavity or into a lumen of an organ.Substantially higher dosages can be used in topical administration.Actual methods for preparing parenterally administrable formulationswill be known or apparent to those skilled in the art and are describedin more detail in such publications as Remington's, supra. See alsoNieman, In “Receptor Mediated Antisteroid Action,” Agarwal, et al.,eds., De Gruyter, New York (1987).

The duration of treatment with SGRM to reduce the tumor load ofcancerous tumor or otherwise ameliorate the symptoms of the tumor canvary according to the severity of the condition in a subject and thesubject's response to SGRMs. In some embodiments, SGRMs can beadministered for a period of about 1 week to 104 weeks (2 years), moretypically about 6 weeks to 80 weeks, most typically about 9 to 60 weeks.Suitable periods of administration also include 5 to 9 weeks, 5 to 16weeks, 9 to 16 weeks, 16 to 24 weeks, 16 to 32 weeks, 24 to 32 weeks, 24to 48 weeks, 32 to 48 weeks, 32 to 52 weeks, 48 to 52 weeks, 48 to 64weeks, 52 to 64 weeks, 52 to 72 weeks, 64 to 72 weeks, 64 to 80 weeks,72 to 80 weeks, 72 to 88 weeks, 80 to 88 weeks, 80 to 96 weeks, 88 to 96weeks, and 96 to 104 weeks. Suitable periods of administration alsoinclude 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 24,25, 30, 32, 35, 40, 45, 48 50, 52, 55, 60, 64, 65, 68, 70, 72, 75, 80,85, 88 90, 95, 96, 100, and 104 weeks. Generally administration of aSGRM should be continued until clinically significant reduction oramelioration is observed. Treatment with the SGRM in accordance with theinvention may last for as long as two years or even longer.

In some embodiments, administration of a SGRM is not continuous and canbe stopped for one or more periods of time, followed by one or moreperiods of time where administration resumes. Suitable periods whereadministration stops include 5 to 9 weeks, 5 to 16 weeks, 9 to 16 weeks,16 to 24 weeks, 16 to 32 weeks, 24 to 32 weeks, 24 to 48 weeks, 32 to 48weeks, 32 to 52 weeks, 48 to 52 weeks, 48 to 64 weeks, 52 to 64 weeks,52 to 72 weeks, 64 to 72 weeks, 64 to 80 weeks, 72 to 80 weeks, 72 to 88weeks, 80 to 88 weeks, 80 to 96 weeks, 88 to 96 weeks, and 96 to 100weeks. Suitable periods where administration stops also include 5, 6, 7,8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 24, 25, 30, 32, 35,40, 45, 48 50, 52, 55, 60, 64, 65, 68, 70, 72, 75, 80, 85, 88 90, 95,96, and 100 weeks.

The dosage regimen also takes into consideration pharmacokineticsparameters well known in the art, i.e., the rate of absorption,bioavailability, metabolism, clearance, and the like (see, e.g.,Hidalgo-Aragones (1996) J Steroid Biochem. Mol. Biol. 58:611-617;Groning (1996) Pharmazie 51:337-341; Fotherby (1996) Contraception54:59-69; Johnson (1995) J. Pharm. Sci. 84:1144-1146; Rohatagi (1995)Pharmazie 50:610-613; Brophy (1983) Eur. J. Clin. Pharmacol. 24:103-108;the latest Remington's, supra). The state of the art allows theclinician to determine the dosage regimen for each individual patient,GR modulator and disease or condition treated.

SGRMs can be used in combination with other active agents known to beuseful in modulating a glucocorticoid receptor, or with adjunctiveagents that may not be effective alone, but may contribute to theefficacy of the active agent.

In some embodiments, co-administration includes administering one activeagent, a SGRM, within 0.5, 1, 2, 4, 6, 8, 10, 12, 16, 20, or 24 hours ofa second active agent. Co-administration includes administering twoactive agents simultaneously, approximately simultaneously (e.g., withinabout 1, 5, 10, 15, 20, or 30 minutes of each other), or sequentially inany order. In some embodiments, co-administration can be accomplished byco-formulation, i.e., preparing a single pharmaceutical compositionincluding both active agents. In other embodiments, the active agentscan be formulated separately. In another embodiment, the active and/oradjunctive agents may be linked or conjugated to one another.

After a pharmaceutical composition including a GR modulator of theinvention has been formulated in an acceptable carrier, it can be placedin an appropriate container and labeled for treatment of an indicatedcondition. For administration of a SGRM, such labeling would include,e.g., instructions concerning the amount, frequency and method ofadministration.

The pharmaceutical compositions of the present invention can be providedas a salt and can be formed with many acids, including but not limitedto hydrochloric, sulfuric, acetic, lactic, tartaric, malic, succinic,etc. Salts tend to be more soluble in aqueous or other protonic solventsthat are the corresponding free base forms. In other cases, thepreparation may be a lyophilized powder in 1 mM-50 mM histidine, 0.1%-2%sucrose, 2%-7% mannitol at a pH range of 4.5 to 5.5, that is combinedwith buffer prior to use.

In another embodiment, the compositions of the present invention areuseful for parenteral administration, such as intravenous (IV)administration or administration into a body cavity or lumen of anorgan. The formulations for administration will commonly comprise asolution of the compositions of the present invention dissolved in apharmaceutically acceptable carrier. Among the acceptable vehicles andsolvents that can be employed are water and Ringer's solution, anisotonic sodium chloride. In addition, sterile fixed oils canconventionally be employed as a solvent or suspending medium. For thispurpose any bland fixed oil can be employed including synthetic mono- ordiglycerides. In addition, fatty acids such as oleic acid can likewisebe used in the preparation of injectables. These solutions are sterileand generally free of undesirable matter. These formulations may besterilized by conventional, well known sterilization techniques. Theformulations may contain pharmaceutically acceptable auxiliarysubstances as required to approximate physiological conditions such aspH adjusting and buffering agents, toxicity adjusting agents, e.g.,sodium acetate, sodium chloride, potassium chloride, calcium chloride,sodium lactate and the like. The concentration of the compositions ofthe present invention in these formulations can vary widely, and will beselected primarily based on fluid volumes, viscosities, body weight, andthe like, in accordance with the particular mode of administrationselected and the patient's needs. For IV administration, the formulationcan be a sterile injectable preparation, such as a sterile injectableaqueous or oleaginous suspension. This suspension can be formulatedaccording to the known art using those suitable dispersing or wettingagents and suspending agents. The sterile injectable preparation canalso be a sterile injectable solution or suspension in a nontoxicparenterally-acceptable diluent or solvent, such as a solution of1,3-butanediol.

H. Chemotherapeutic Agents

Chemotherapeutic agents suitable for use in combination with the SGRM ofthe invention include agents that have the property of killing cancercells or inhibiting cancer cell growth, such as those disclosed in USPat. Pub. No. 20150218274, and alsohttp://chemocare.com/chemotherapy/what-is-chemotherapy/types-of-chemotherapy.aspx.These agents include, but are not limited to antimicrotubule agents(e.g., taxanes and vinca alkaloids), topoisomerase inhibitors andantimetabolites (e.g., nucleoside analogs acting as such, for example,Gemcitabine), mitotic inhibitors, alkylating agents, antimetabolites,anti-tumor antibiotics, mitotic inhibitors, anthracyclines,intercalating agents, agents capable of interfering with a signaltransduction pathway, agents that promote apoptosis, proteosomeinhibitors, and alike.

Alkylating agents are most active in the resting phase of the cell.These types of drugs are cell-cycle non-specific. Exemplary alkylatingagents that can be used in combination with the SGRM of the inventioninclude, without limitation, nitrogen mustards, ethyleniminederivatives, alkyl sulfonates, nitrosoureas and triazenes): uracilmustard (Aminouracil Mustard®, Chlorethaminacil®, Demethyldopan®,Desmethyldopan®, Haemanthamine®, Nordopan®, Uracil nitrogen Mustard®,Uracillost®, Uracilmostaza®, Uramustin®, Uramustine®), chlormethine(Mustargen®), cyclophosphamide (Cytoxan®, Neosar®, Clafen®, Endoxan®,Procytox®, Revimmune.TM.), ifosfamide (Mitoxana®), melphalan (Alkeran®),Chlorambucil (Leukeran®), pipobroman (Amedel®, Vercyte®),triethylenemelamine (Hemel®, Hexalen®, Hexastat®),triethylenethiophosphoramine, thiotepa (Thioplex®), busulfan (Busilvex®,Myleran®), carmustine (BiCNU®), lomustine (CeeNU®), streptozocin(Zanosar®), and Dacarbazine (DTIC-Dome®). Additional exemplaryalkylating agents include, without limitation, Oxaliplatin (Eloxatin®);Temozolomide (Temodar® and Temodal®); Dactinomycin (also known asactinomycin-D, Cosmegen®); Melphalan (also known as L-PAM, L-sarcolysin,and phenylalanine mustard, Alkeran®); Altretamine (also known ashexamethylmelamine (HMM), Hexalen®); Carmustine (BiCNU®); Bendamustine(Treanda®); Busulfan (Busulfex® and Myleran®); Carboplatin(Paraplatin®); Lomustine (also known as CCNU, CeeNU®); Cisplatin (alsoknown as CDDP, Platinol® and Platinol®-AQ); Chlorambucil (Leukeran®);Cyclophosphamide (Cytoxan® and Neosar®); Dacarbazine (also known asDTIC, DIC and imidazole carboxamide, DTIC-Dome®); Altretamine (alsoknown as hexamethylmelamine (HMM), Hexalen®); Ifosfamide (Ifex®);Prednumustine; Procarbazine (Matulane®); Mechlorethamine (also known asnitrogen mustard, mustine and mechloroethamine hydrochloride,Mustargen®); Streptozocin (Zanosar®); Thiotepa (also known asthiophosphoamide, TESPA and TSPA, Thioplex®); Cyclophosphamide(Endoxan®, Cytoxan®, Neosar®, Procytox®, Revimmune®); and BendamustineHC1 (Treanda®).

Antitumor antibiotics are chemo agents obtained from natural productsproduced by species of the soil fungus Streptomyces. These drugs actduring multiple phases of the cell cycle and are considered cell-cyclespecific. There are several types of antitumor antibiotics, includingbut are not limited to Anthracyclines (e.g., Doxorubicin, Daunorubicin,Epirubicin, Mitoxantrone, and Idarubicin), Chromomycins (e.g.,Dactinomycin and Plicamycin), Mitomycin and Bleomycin.

Antimetabolites are types of chemotherapy treatments that are cell-cyclespecific. When the cells incorporate these antimetabolite substancesinto the cellular metabolism, they are unable to divide. These class ofchemotherapy agents include folic acid antagonists such as Methotrexate;pyrimidine antagonists such as 5-Fluorouracil, Foxuridine, Cytarabine,Capecitabine, and Gemcitabine; purine antagonists such as6-Mercaptopurine and 6-Thioguanine; Adenosine deaminase inhibitors suchas Cladribine, Fludarabine, Nelarabine and Pentostatin.

Exemplary anthracyclines that can be used in combination with the SGRMof the invention include, e.g., doxorubicin (Adriamycin® and Rubex®);Bleomycin (Lenoxane®); Daunorubicin (dauorubicin hydrochloride,daunomycin, and rubidomycin hydrochloride, Cerubidine®); Daunorubicinliposomal (daunorubicin citrate liposome, DaunoXome®); Mitoxantrone(DHAD, Novantrone®); Epirubicin (Ellence); Idarubicin (Idamycin®,Idamycin PFS®); Mitomycin C (Mutamycin®); Geldanamycin; Herbimycin;Ravidomycin; and Desacetylravidomycin.

Antimicrotubule agents include vinca alkaloids and taxanes. Exemplaryvinca alkaloids that can be used in combination with the SGRM of theinvention include, but are not limited to, vinorelbine tartrate(Navelbine®), Vincristine (Oncovin®), and Vindesine (Eldisine®));vinblastine (also known as vinblastine sulfate, vincaleukoblastine andVLB, Alkaban-AQ® and Velban®); and vinorelbine (Navelbine®). Exemplarytaxanes that can be used in combination with the SGRM of the inventioninclude, but are not limited to paclitaxel and docetaxel. Non-limitingexamples of paclitaxel agents include nanoparticle albumin-boundpaclitaxel (“nab-paclitaxel”, marketed as ABRAXANE by AbraxisBioscience), docosahexaenoic acid bound-paclitaxel (DHA-paclitaxel,Taxoprexin, marketed by Protarga), polyglutamate bound-paclitaxel(PG-paclitaxel, paclitaxel poliglumex, CT-2103, XYOTAX, marketed by CellTherapeutic), the tumor-activated prodrug (TAP), ANG105 (Angiopep-2bound to three molecules of paclitaxel, marketed by ImmunoGen),paclitaxel-EC-1 (paclitaxel bound to the erbB2-recognizing peptide EC-1;see Li et al., Biopolymers (2007) 87:225-230), and glucose-conjugatedpaclitaxel (e.g., 2′-paclitaxel methyl 2-glucopyranosyl succinate, seeLiu et al., Bioorganic & Medicinal Chemistry Letters (2007) 17:617-620).

Exemplary proteosome inhibitors that can be used in combination with theSGRM of the invention, include, but are not limited to, Bortezomib(Velcade.®.); Carfilzomib (PX-171-007,(S)-4-Methyl-N—((S)-1-(((S)-4-methyl-1-((R)-2-methyloxiran-2-yl)-1-oxope-ntan-2-yl)amino)-1-oxo-3-phenylpropan-2-yl)-2-(S)-2-(2-morpholinoacetamid-o)-4-phenylbutanamido)-pentanamide);marizomib (NPI-0052); ixazomib citrate (MLN-9708); delanzomib(CEP-18770); andO-Methyl-N-[(2-methyl-5-thiazolyl)carbonyl]-L-seryl-O-methyl-N-[(1S)-2-[(-2R)-2-methyl-2-oxiranyl]-2-oxo-1-(phenylmethyl)ethyl]-L-serinamide(ONX-0912).

In some embodiments, the chemotherapeutic agent is selected from thegroup consisting of chlorambucil, cyclophosphamide, ifosfamide,melphalan, streptozocin, carmustine, lomustine, bendamustine,uramustine, estramustine, carmustine, nimustine, ranimustine,mannosulfan busulfan, dacarbazine, temozolomide, thiotepa, altretamine,5-fluorouracil (5-FU), 6-mercaptopurine (6-MP), capecitabine,cytarabine, floxuridine, fludarabine, gemcitabine, hydroxyurea,methotrexate, pemetrexed, daunorubicin, doxorubicin, epirubicin,idarubicin, SN-38, ARC, NPC, campothecin, topotecan,9-nitrocamptothecin, 9-aminocamptothecin, rubifen, gimatecan,diflomotecan, BN80927, DX-895 If, MAG-CPT, amsacrine, etoposide,etoposide phosphate, teniposide, doxorubicin, paclitaxel, docetaxel,gemcitabine, accatin III, 10-deacetyltaxol, 7-xylosyl-10-deacetyltaxol,cephalomannine, 10-deacetyl-7-epitaxol, 7-epitaxol, 10-deacetylbaccatinIII, 10-deacetyl cephalomannine, gemcitabine, Irinotecan, albumin-boundpaclitaxel, Oxaliplatin, Capecitabine, Cisplatin, docetaxel, irinotecanliposome, and etoposide, and combinations thereof.

In certain embodiments, the chemotherapeutic agent is administered at adose and a schedule that may be guided by doses and schedules approvedby the U.S. Food and Drug Administration (FDA) or other regulatory body,subject to empirical optimization. In some cases, the chemotherapeuticagent is administered at a dose of about 100 to 1000 mg, e.g., about 200mg to 800 mg, about 300 mg to 700 mg, or about 400 mg to 600 mg, e.g.,about 200 mg, 300 mg, 400 mg, 500 mg, 600 mg, or 700 mg. The dosingschedule can vary from, e.g. every week, every five days, every fourdays, every other day to daily, twice, or three times a day. In oneembodiment, the chemotherapeutic agent is administered at an oral doseor an intravenous dose from about 100 mg to 600 mg daily, e.g., about100 mg, 200 mg, 260 mg, 300 mg, 400 mg, or 600 mg daily, every other dayor every four days for the whole or a portion of the treatment period.In some embodiments, the chemotherapeutic agent is a taxane and can beused at any standard dose, for example those approved by the FDA, inaccordance with the methods of the invention. In various embodiments,the taxane is nab-paclitaxel, which is administered at a dose rangingfrom 80 mg to 125 mg per square meter of body-surface area as anintravenous infusion over 30 minutes on days 1, 8, and 15 of every28-day cycle.

In still further embodiments, more than one chemotherapeutic agent maybe administered simultaneously, or sequentially in any order during theentire or portions of the treatment period. The two agents may beadministered following the same or different dosing regimens.

I. Combination Therapies

Various combinations with a SGRM and a chemotherapeutic agent (or acombination of such agents and compounds) may be employed to reduce thetumor load in the patient. By “combination therapy” or “in combinationwith”, it is not intended to imply that the therapeutic agents must beadministered at the same time and/or formulated for delivery together,although these methods of delivery are within the scope describedherein. The SGRM and the chemotherapeutic agent can be administeredfollowing the same or different dosing regimen. In some embodiments, theSGRM and the chemotherapeutic agent is administered sequentially in anyorder during the entire or portions of the treatment period. In someembodiments, the SGRM and the anticancer agent is administeredsimultaneously or approximately simultaneously (e.g., within about 1, 5,10, 15, 20, or 30 minutes of each other). Non-limiting examples ofcombination therapies are as follows, with administration of the SGRMand the chemo agent for example, SGRM is “A” and the anticancer agent orcompound, given as part of an chemo therapy regime, is “B”:

A/B/AB/A/BB/B/AA/A/BA/B/BB/A/AA/B/B/B B/A/B/B

B/B/B/A B/B/A/B A/A/B/B AB/AB A/B/B/A B/B/A/A

B/A/B/A B/A/A/B A/A/A/B B/A/A/A A/B/A/A A/A/B/A

Administration of the therapeutic compounds or agents to a patient willfollow general protocols for the administration of such compounds,taking into account the toxicity, if any, of the therapy. Surgicalintervention may also be applied in combination with the descirbedtherapy.

The present methods involvincan be combined with other means oftreatment such as surgery, radiation, targeted therapy, immunotherapy,use of growth factor inhibitors, or anti-angiogenesis factors.

J. Evaluate Improvements in Reducing Tumor Loads

The SGRM therapy disclosed herein can reduce the tumor load and conferbeneficial clinical outcome to patients having a cancerous tumor.Methods for measuring these responses are well-known to skilled artisansin the field of cancer therapy, e.g., as described in the ResponseEvaluation Criteria in Solid Tumors (“RECIST”) guidelines, available atctep.cancer.gov/protocolDevelopment/docs/recist_guideline.pdf.

In one approach, the tumor load is measured by assaying expression oftumor-specific biomarkers. This approach is especially useful formetastatic tumors. A tumor-specific biomarker is a protein or othermolecule that is unique to cancer cells or is much more abundant in themas compared to non-cancer cells. Biomarkers believed to be useful foridentifying cervical cancer include, for example, alpha actinin-4,pyruvate kinase isozyme M1/M2, and others (see, e.g., Van Raemdonck etal., PLoS One September 2014,http://dx.doi.org/10.1371/jounal.pone.0160488).

Methods of measuring the expression levels of a tumor-specific geneticmarker are well known. In some embodiments, mRNA of the genentic markeris isolated from the blood sample or a tumor tissue and real-timereverse transcriptase-polymerase chain reaction (RT-PCR) is performed toquantify expression of the genetic marker. In some embodiments, westernblots or immunohistochemistry analysis are performed to evaluate theprotein expression of the tumor-specific genetic marker. Typically thelevels of the tumor-specific genetic marker are measured in multiplesamples taken over time of the combination therapy of the invention, anda decrease in levels correlates with a reduction in tumor load.

In another approach, the reduction of tumor load by the combinationtherapy disclosed herein is shown by a reduction in tumor size or areduction of amount of cancer in the body. Measuring tumor size istypically achieved by imaging-based techniques. For example, computedtomography (CT) scan can provide accurate and reliable anatomicinformation about not only tumor shrinkage or growth but alsoprogression of disease by identifying either growth in existing lesionsor the development of new lesions or tumor metastasis.

In yet another approach, a reduction of tumor load can be assessed byfunctional and metabolic imaging techniques. These techniques canprovide earlier assessment of therapy response by observing alterationsin perfusion, oxygenation and metabolism. For example, ¹⁸F-FDG PET usesradiolabelled glucose analogue molecules to assess tissue metabolism.Tumors typically have an elevated uptake of glucose, a change in valuecorresponding to a decrease in tumor tissue metabolism indicates areduction in tumor load. Similar imaging techniques are disclosed inKang et al., Korean J. Radiol. (2012) 13(4) 371-390.

A patient receiving the therapy disclosed herein may exhibit varyingdegrees of tumor load reduction. In some cases, a patient can exhibit aComplete Response (CR), also referred to as “no evidence of disease(NED)”. CR means all detectable tumor has disappeared as indicated bytests, physical exams and scans. In some cases, a patient receiving thecombination therapy disclosed herein can experience a Partial Response(PR), which roughly corresponds to at least a 50% decrease in the totaltumor volume but with evidence of some residual disease still remaining.In some cases the residual disease in a deep partial response mayactually be dead tumor or scar so that a few patients classified ashaving a PR may actually have a CR. Also many patients who showshrinkage during treatment show further shrinkage with continuedtreatment and may achieve a CR. In some cases, a patient receiving thecombination therapy can experience a Minor Response (MR), which roughtlymeans a small amount of shrinkage that is more than 25% of total tumorvolume but less than the 50% that would make it a PR. In some cases, apatient receiving the combination therapy can exhibit Stable Disease(SD), which means the tumors stay roughly the same size, but can includeeither a small amount of growth (typically less than 20 or 25%) or asmall amount of shrinkage (Anything less than a PR unless minorresponses are broken out. If so, then SD is defined as typically less25%).

Desired beneficial or desired clinical results from the combinationtherapy may also include e. g., reduced (i.e., slowing to some extentand/or stop) cancer cell infiltration into peripheral organs; inhibited(i.e., slowing to some extent and/or stop) tumor metastasis; increasedresponse rates (RR); increased duration of response; relieved to someextent one or more of the symptoms associated with the cancer; decreaseddose of other medications required to treat the disease; delayedprogression of the disease; and/or prolonged survival of patients and/orimproved quality of life. Methods for evaluating these effects are wellknown and/or disclosed in, e.g., cancerguide.org/endpoints.html andRECIST guidelines, supra.

All publications and patent applications cited in this specification arehereby incorporated by reference herein in their entireties as if eachindividual publication or patent application were specifically andindividually indicated to be incorporated by reference.

Although the foregoing invention has been described in some detail byway of illustration and example for purposes of clarity ofunderstanding, it will be readily apparent to those of ordinary skill inthe art in light of the teachings of this invention that certain changesand modifications may be made thereto without departing from the spiritor scope of the appended claims.

EXAMPLES

The following examples are provided by way of illustration only and notby way of limitation. Those of skill will readily recognize a variety ofnoncritical parameters which could be changed or modified to yieldessentially similar results.

Example 1 HEPG2 Tyrosine Aminotransferase (TAT) Assay

The following protocol describes an assay for measuring induction of TATby dexamethasone in HepG2 cells (a human liver hepatocellular carcinomacell line; ECACC, UK). HepG2 cells are cultured using MEME mediasupplemented with 10% (v/v) foetal bovine serum; 2 mM L-glutamine and 1%(v/v) NEAA at 37° C., 5%/95% (v/v) CO₂/air. The HepG2 cells are then becounted and adjusted to yield a density of 0.125×10⁶ cells/ml in RPMI1640 without phenol red, 10% (v/v) charcoal stripped FBS, 2 mML-glutamine and seeded at 25,000 cells/well in 200 μl into 96 well,sterile, tissue culture micro titre plates, and incubated at 37° C., 5%CO₂ for 24 hours.

Growth media are then removed and replaced with assay media {RPMI 1640without phenol red, 2 mM L-glutamine +10 μM forskolin}. Test compoundsare then be screened against a challenge of 100 nM dexamethasone.Compounds are then be serially half log diluted in 100% (v/v)dimethylsupfoxide from a 10 mM stock. Then an 8-point half-log dilutioncurve are generated followed by a 1:100 dilution into assay media togive a 10× final assay of the compound concentration, this results infinal assay of the compound concentration that ranged 10 to 0.003 μM in0.1% (v/v) dimethylsulfoxide.

Test compounds are pre-incubated with cells in micro-titre plates for 30minutes at 37° C., 5/95 (v/v) CO₂/air, before the addition of 100 nMdexamethasone and then subsequently for 20 hours to allow optimal TATinduction.

HepG2 cells are then lysed with 30 μl of cell lysis buffer containing aprotease inhibitor cocktail for 15 minutes at 4° C. 155 μl of substratemixture can then be added containing 5.4 mM Tyrosine sodium salt, 10.8mM alpha ketoglutarate and 0.06 mM pyridoxal 5′ phosphate in 0.1 Mpotassium phosphate buffer (pH 7.4). After 2 hours incubation at 37° C.the reaction can be terminated by the addition of 15 μl of 10 M aqueouspotassium hydroxide solution, and the plates incubated for a further 30minutes at 37° C. The TAT activity product can be measured by absorbanceat λ 340 nm.

IC₅₀ values can be calculated by plotting % inhibition (normalised to100 nM dexamethasone TAT stimulation) v. compound concentration andfitting the data to a 4 parameter logistic equation. IC₅₀ values canconverted to Ki (equilibrium dissociation constant) using the Cheng andPrusoff equation, assuming the antagonists were competitive inhibitorswith respect to dexamethasone.

Example 2 Reducing Implanted Cervical Cancer Tumor Growth in Mice Usingthe Combination Therapy of CORT125134 and Paclitaxel

Suspensions of human HeLa cervical cancer cells were injectedsubcutaneously into the right flank of 5-6 week old immunosuppressedfemale mice (BALB/c nude), five million cells per mouse. Tumors wereallowed to grow until they reached a volume of 100-200 mm³. Mice werethen grouped into five groups, ten (10) per group. Group 1 was dosedwith the paclitaxel vehicle (sterile saline) intravenously (i.v.) every4 days and the CORT125134 vehicle orally (p.o.) (10% DMSO, 0.1% Tween 80and 89.9% HPMC (0.5%), 10 ml/kg) every 4 days. Group 2 was dosed withpaclitaxel (7.5 mg/kg) i.v. every 4 days. Group 3 was dosed withpaclitaxel i.v. every 4 days and with CORT125134 (30 mg/kg) p.o. the daybefore the administration of paclitaxel and the same day as theadministration of paclitaxel. Group 4 received paclitaxel (15 mg/kg)i.v. every 4 days. Group 5 received paclitaxel (15 mg/kg) i.v. every 4days and CORT125134 (30 mg/kg) p.o. the day before and the day ofpaclitaxel (15 mg/kg) i.v. administration.

The longest (L) and shortest (S) diameters of the tumors were measuredthree times a week with electronic calipers and tumor volume wascalculated using the formula for an ellipsoid sphere: S²×L×(0.5). Thetumor growth data are shown in FIG. 1, in which the mean tumor volumefor each group of mice is plotted against the number of days of tumorgrowth since initiation of the treatment. Table 1 provides a summary ofthe results. All treatments provide benefit compared to vehicle alone.The combination of paclitaxel and CORT125134 is more effective thanpaclitaxel alone, for either dose of paclitaxel.

TABLE 1 Comparison p Group 1 vs Group 2 0.0281 Group 1 vs Group 4 0.0006Group 2 vs Group 3 0.008 Group 4 vs Group 5 <0.0001 Group 3 vs Group 50.0009

Example 2 Treating Triple-Negative Breast Cancer Explants withCORT125134 in Combination with Paclitaxel

MDA-MB-231 cells (10 million cells per mouse) were injectedorthotopically in the right mammary fat pad in groups of female Balb/cnude mice. When the tumors reached a volume of 100-200 mm3, the micewere randomized into groups of 10 and treatment was initiated. Mice weretreated as follows: group 1 received vehicle daily, group 2 receivedpaclitaxel 5 mg/kg i.v. every 4 days, group 3 received paclitaxel 5mg/kg i.v. every 4 days and CORT125134 30 mg/kg p.o. daily. Tumorvolumes were measured 3 times a week in 2 dimensions using a caliper andthe volume expressed in mm3 using the formula V=0.5 a×b2 where a and bare the long and short diameters of the tumor, respectively. Dosing wascontinued for 28 days, but any mouse in poor condition or with a tumorexceeding 3000 mm3 was terminated. For comparison between two groups anindependent sample t-test was used; for comparison among three or moregroups a one-way ANOVA was performed followed by multiple comparisonprocedures. A p-value <0.05 was considered to be statisticallysignificant. The effect of CORT125134 in combination with paclitaxel ina triple negative breast cancer (TNBC) mouse xenograft model is shown inFIG. 2. Data represent mean+SEM. The administration of paclitaxel at adose of 5 mg/kg was ineffective in this model, p=not significantcompared with vehicle treated mice. The combination of paclitaxel andCORT125134 achieved a significant inhibition of tumor growth compared tovehicle treated mice (p<0.05) or compared to the use of paclitaxel alone(p<0.05).

Example 3 Treating Ovarian Cancer Explants with CORT125134 inCombination with Gemcitabine/Carboplatin

The effect of CORT125134 in combination with gemcitabine/carboplatin inan ovarian cancer mouse xenograft model is shown in FIG. 3 presentingresults from groups of 10 mice per group. CORT125134 was administeredintraperitoneally (i.p.) on days 43, 44, 50 and 51, andgemcitabine/carboplatin was administered i.p. on days 44 and 51. Datarepresent mean values. SK-OV-3 cells (5 million cells per mouse) wereinjected in the right flank of female Balb/c nude mice. When tumorsreached a volume of 200 mm³ the mice were randomized into groups of 10and treatment was initiated. Mice were treated as follows: group 1received vehicle on dosing days 1, 2, 8 and 9, group 2 receivedgemcitabine (80 mg/kg i.p.) and carboplatin (15 mg/kg i.p.) on dosingdays 2 and 9 and group 3 received gemcitabine/carboplatin in the sameregimen as group 2, +CORT125134 (20 mg/kg i.p.) on dosing days 1, 2, 8and 9. Tumor volumes were measured 3 times a week and tumor volumes werecalculated as detailed above. Any mouse in poor condition or with atumor exceeding 2000 mm³ was terminated. The results were analyzed asindicated in Example 2 above. The administration ofgemcitabine/carboplatin at these doses was ineffective in the SK-OV-3model (p=NS vs vehicle-treated mice). The combination ofgemcitabine/carboplatin with CORT125134 achieved a significantinhibition of tumor growth compared to vehicle (p<0.001), and comparedwith carboplatin/gemcitabine (p<0.01).

Example 4 Treating Prostate Cancer Explants with CORT125134 in CastratedMice

The effect of CORT125134 in combination with castration in a prostatecancer (CRPC) mouse xenograft model is presented in FIG. 4. 22Rv1 cells(10 million cells per mouse) were injected in the right flank of maleBalb/c nude mice. When the tumors reached a volume of 100-200 mm³ themice were randomized into groups of 10 and then 2 of the 3 groups werecastrated. Treatment was initiated the day after castration as follows:group 1 (not castrated) received vehicle, group 2 (castrated) receivedvehicle, and group 3 (castrated) received CORT125134 30 mg/kg orally(p.o.) daily for 21 days. Tumor volumes were measured 3 times a week asdescribed previously. Any mouse in poor condition or with a tumorexceeding 3000 mm³ was terminated. The results were analyzed asindicated in Example 2 above. Data represent mean+SEM. Mice that werecastrated exhibited reduced tumor growth compared with mice that werenot castrated (p<0.0001). The administration of CORT125134 to castratedmice also inhibited tumor growth compared to mice that were notcastrated (p<0.0001). The combination of castration and CORT125134 wasmore effective than castration alone (p<0.05).

Example 5 Treating a Patient Having Cervical Cancer with SGRM and anChemotherapeutic Agent

A 68-year-old female patient complains of upper abdomen pain. She isexperiencing loss of appetite, nausea and vomiting episodes, andsignificant weight loss. A CT scan shows what is suspected to be a tumorin the cervix. The suspected tumor is confirmed by histological analysisto be a cancerous tumor. The patient is treated with CORT125134 at adose of 200 mg once a day for eight weeks in combination with anintravenous infusion of nab-paclitaxel at a dose of 80 mg per squaremeter of body-surface area as an intravenous infusion over 30 minutes ondays 1, 8, and 15 of every 28-day cycle. Tumor load is monitored usingenhanced Mill before, during and after the treatment. The imagingindicate that tumor size is decreasing, and the reduction is more than50% at the end of the treatment period.

What is claimed is:
 1. A method of treating a subject hosting acancerous tumor, the method comprising administering to the subject aneffective amount of a chemotherapeutic agent and an effective amount ofnon-steroidal selective glucocorticoid receptor modulator (SGRM) toreduce the tumor load of the cancerous tumor.
 2. The method of claim 1,wherein cancerous tumor is a cervical cancer tumor.
 3. The method ofclaim 1, wherein the chemotherapeutic agent is selected from the groupconsisting of taxanes, alkylating agents, topoisomerase inhibitors,endoplasmic reticulum stress inducing agents, antimetabolites, mitoticinhibitors and combinations thereof.
 4. The method of claim 3, whereinthe chemotherapeutic agent is a taxane.
 5. The method of claim 3,wherein the chemotherapeutic agent is selected from the group consistingof nab-paclitaxel, 5-fluorouracil (5-FU), gemcitabine, cisplatin andcapecitabine.
 6. The method of claim 1, wherein the glucocorticoidreceptor modulator backbone is a fused azadecalin.
 7. The method ofclaim 6, wherein the fused azadecalin is a compound having the followingformula:

wherein L¹ and L² are members independently selected from a bond andunsubstituted alkylene; R¹ is a member selected from unsubstitutedalkyl, unsubstituted heteroalkyl, unsubstituted heterocycloalkyl,—OR^(1A), NR^(1C)R^(1D), —C(O)NR^(1C)R^(1D), and —C(O)OR^(1A), whereinR^(1A) is a member selected from hydrogen, unsubstituted alkyl andunsubstituted heteroalkyl, R^(1C) and R^(1D) are members independentlyselected from unsubstituted alkyl and unsubstituted heteroalkyl, whereinR^(1C) and R^(1D) are optionally joined to form an unsubstituted ringwith the nitrogen to which they are attached, wherein said ringoptionally comprises an additional ring nitrogen; R² has the formula:

wherein R^(2G) is a member selected from hydrogen, halogen,unsubstituted alkyl, unsubstituted heteroalkyl, unsubstitutedcycloalkyl, unsubstituted heterocycloalkyl, —CN, and —CF₃; J is phenyl;t is an integer from 0 to 5; X is —S(O₂)—; and R⁵ is phenyl optionallysubstituted with 1-5 R^(5A) groups, wherein R^(5A) is a member selectedfrom hydrogen, halogen, —OR^(5A1), S(O₂)NR^(5A2)R^(5A3), —CN, andunsubstituted alkyl, wherein R^(5A1) is a member selected from hydrogenand unsubstituted alkyl, and R^(5A2) and R^(5A3) are membersindependently selected from hydrogen and unsubstituted alkyl, or saltsand isomers thereof.
 8. The method of claim 6, wherein the fusedazadecalin is:


9. The method of claim 6, wherein the glucocorticoid receptor modulatorbackbone is a heteroaryl ketone fused azadecalin or an octahydro fusedazadecalin.
 10. The method of claim 9, wherein the heteroaryl ketonefused azadecalin has the formula:

wherein R¹ is a heteroaryl ring having from 5 to 6 ring members and from1 to 4 heteroatoms each independently selected from the group consistingof N, O and S, optionally substituted with 1-4 groups each independentlyselected from R^(1a); each R^(1a) is independently selected from thegroup consisting of hydrogen, C₁₋₆ alkyl, halogen, C₁₋₆ haloalkyl, C₁₋₆alkoxy, C₁₋₆ haloalkoxy, CN, N-oxide, C₃₋₈ cycloalkyl, and C₃₋₈heterocycloalkyl; ring J is selected from the group consisting of acycloalkyl ring, a heterocycloalkyl ring, an aryl ring and a heteroarylring, wherein the heterocycloalkyl and heteroaryl rings have from 5 to 6ring members and from 1 to 4 heteroatoms each independently selectedfrom the group consisting of N, O and S; each R¹ is independentlyselected from the group consisting of hydrogen, C₁₋₆ alkyl, halogen,C₁₋₆ haloalkyl, C₁₋₆ alkoxy, C₁₋₆ haloalkoxy, C₁₋₆ alkyl-C₁₋₆ alkoxy,CN, OH, NR^(2a)R^(2b), C(O)R^(2a), C(O)OR^(2a), C(O)NR^(2a)R^(2b),SR^(2a), S(O)R^(2a), S(O)₂R^(2a), C₃₋₈ cycloalkyl, and C₃₋₈heterocycloalkyl, wherein the heterocycloalkyl groups are optionallysubstituted with 1-4 R^(2c) groups; alternatively, two R² groups linkedto the same carbon are combined to form an oxo group (═O);alternatively, two R² groups are combined to form a heterocycloalkylring having from 5 to 6 ring members and from 1 to 3 heteroatoms eachindependently selected from the group consisting of N, O and S, whereinthe heterocycloalkyl ring is optionally substituted with from 1 to 3R^(2d) groups; R^(2a) and R^(2b) are each independently selected fromthe group consisting of hydrogen and C₁₋₆ alkyl; each R^(2c) isindependently selected from the group consisting of hydrogen, halogen,hydroxy, C₁₋₆ alkoxy, C₁₋₆ haloalkoxy, CN, and NR^(2a)R^(2b); eachR^(2d) is independently selected from the group consisting of hydrogenand C₁₋₆ alkyl, or two R^(2d) groups attached to the same ring atom arecombined to form (═O); R³ is selected from the group consisting ofphenyl and pyridyl, each optionally substituted with 1-4 R^(3a) groups;each R^(3a) is independently selected from the group consisting ofhydrogen, halogen, and C₁₋₆ haloalkyl; and subscript n is an integerfrom 0 to 3; or salts and isomers thereof.
 11. The method of claim 9,wherein the heteroaryl-ketone fused azadecalin is


12. The method of claim 9, wherein the octahydro fused azadecalin hasthe formula:

wherein R¹ is a heteroaryl ring having from 5 to 6 ring members and from1 to 4 heteroatoms each independently selected from the group consistingof N, O and S, optionally substituted with 1-4 groups each independentlyselected from R^(1a); each R^(1a) is independently selected from thegroup consisting of hydrogen, C₁₋₆ alkyl, halogen, C₁₋₆ haloalkyl, C₁₋₆alkoxy, C₁₋₆ haloalkoxy, N-oxide, and C₃₋₈ cycloalkyl; ring J isselected from the group consisting of an aryl ring and a heteroaryl ringhaving from 5 to 6 ring members and from 1 to 4 heteroatoms eachindependently selected from the group consisting of N, O and S; each R²is independently selected from the group consisting of hydrogen, C₁₋₆alkyl, halogen, C₁₋₆ haloalkyl, C₁₋₆ alkoxy, C₁₋₆ haloalkoxy, C₁₋₆alkyl-C₁₋₆ alkoxy, CN, OH, NR^(2a)R^(2b), C(O)R^(2a), C(O)OR^(2a),C(O)NR^(2a)R^(2b), SR^(2a), S(O)R^(2a), S(O)₂R^(2a), C₃₋₈ cycloalkyl,and C₃₋₈ heterocycloalkyl having from 1 to 3 heteroatoms eachindependently selected from the group consisting of N, O and S;alternatively, two R² groups on adjacent ring atoms are combined to forma heterocycloalkyl ring having from 5 to 6 ring members and from 1 to 3heteroatoms each independently selected from the group consisting of N,O and S, wherein the heterocycloalkyl ring is optionally substitutedwith from 1 to 3 R^(2c) groups; R^(2a), R^(2b) and R^(2c) are eachindependently selected from the group consisting of hydrogen and C₁₋₆alkyl; each R^(3a) is independently halogen; and subscript n is aninteger from 0 to 3, or salts and isomers thereof.
 13. The method ofclaim 9, wherein the octahydro fused azadecalin has the formula: